title: Systematic Review of Ambulatory Transitional Care Management (TCM) Visits on Hospital 30-Day Readmission Rates.
abstract: To reduce readmission rates and prevent adverse outcomes after discharge, hospitals have begun implementing "transitional care" initiatives. This systematic review identifies research on the particular set of services now reimbursable by Medicare (transitional care management [TCM]) and evaluates the studies for program effectiveness. Results of 3 databases were screened for peer-reviewed journal articles published between January 2004 and 2015 that report on readmissions of adults in the US health care system under the Medicare TCM bundle. ClinicalTrials.gov was queried for funded studies. Of 969 identified studies, 77 met inclusion criteria for relevance to transitional care and appropriateness of population and setting. Of these, only 3 articles incorporated all required elements for TCM service. Although 2 were program improvement designs and none were randomized controlled studies, each report reduced readmission rates. Evidence for TCM effectiveness is limited. Additional study of TCM implementation and programmatic support for TCM is warranted.
authors.affiliation: 1 University of Kentucky, College of Medicine, Department of Family and Community Medicine, Lexington, KY.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Roper
authors.affiliation: 1 University of Kentucky, College of Medicine, Department of Family and Community Medicine, Lexington, KY.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ballard
authors.affiliation: 1 University of Kentucky, College of Medicine, Department of Family and Community Medicine, Lexington, KY.
authors.forename: Wade
authors.initials: W
authors.lastname: Rankin
authors.affiliation: 1 University of Kentucky, College of Medicine, Department of Family and Community Medicine, Lexington, KY.
authors.forename: Roberto
authors.initials: R
authors.lastname: Cardarelli
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D003142:Communication; D006801:Humans; D006278:Medicare; D059065:Medication Reconciliation / Q000458:organization & administration; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D000069341:Transitional Care / Q000458:organization & administration*; D014481:United States
keywords: 30-day readmission; chronic disease; systematic review; transitional care