title: Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.
abstract: Recurrent hospitalizations represent a substantial and often preventable human and financial burden in the United States. In 2008 North Carolina initiated a statewide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. In a study of patients hospitalized during 2010-11, we found that those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. This study suggests that locally embedded, targeted care coordination interventions can effectively reduce hospitalizations for high-risk populations.
authors.affiliation: Community Care of North Carolina, Raleigh, NC, USA.
authors.forename: Carlos T
authors.initials: CT
authors.lastname: Jackson
authors.forename: Troy K
authors.initials: TK
authors.lastname: Trygstad
authors.forename: Darren A
authors.initials: DA
authors.lastname: DeWalt
authors.forename: C Annette
authors.initials: CA
authors.lastname: DuBard
mesh_terms: D000368:Aged; D019090:Case Management / Q000191:economics / Q000706:statistics & numerical data; D002908:Chronic Disease / Q000191:economics* / Q000534:rehabilitation; D003153:Community Health Services / Q000191:economics*; D003266:Continuity of Patient Care / Q000191:economics* / Q000706:statistics & numerical data; D017046:Cost Savings / Q000191:economics*; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid / Q000191:economics* / Q000706:statistics & numerical data; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D009657:North Carolina; D010359:Patient Readmission / Q000191:economics* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000191:economics* / Q000706:statistics & numerical data; D018570:Risk Assessment; D014481:United States; D014600:Utilization Review
keywords: Chronic Care; Hospitalizations; Medicaid; Primary Care