title: Impact of an integrated transition management program in primary care on hospital readmissions.
abstract: Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.
authors.forename: Timothy W
authors.initials: TW
authors.lastname: Farrell
authors.forename: Andrada
authors.initials: A
authors.lastname: Tomoaia-Cotisel
authors.forename: Debra L
authors.initials: DL
authors.lastname: Scammon
authors.forename: Kimberly
authors.initials: K
authors.lastname: Brunisholz
authors.forename: Jaewhan
authors.initials: J
authors.lastname: Kim
authors.forename: Julie
authors.initials: J
authors.lastname: Day
authors.forename: Lisa H
authors.initials: LH
authors.lastname: Gren
authors.forename: Stephanie
authors.initials: S
authors.lastname: Wallace
authors.forename: Karen
authors.initials: K
authors.lastname: Gunning
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tabler
authors.forename: Michael K
authors.initials: MK
authors.lastname: Magill
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration*; D012189:Retrospective Studies; D014589:Utah