title: Impact of a scalable care transitions program for readmission avoidance.
abstract: OBJECTIVE
  To evaluate the Care Transition Solution (CTS) as a means to improve quality through reduction of preventable hospital readmissions among patients with readmission-sensitive conditions subject to penalties imposed by the Affordable Care Act.
  
  
  METHODS
  A retrospective quasi-experimental evaluation of the impact of the CTS among admitted patients diagnosed with heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and/or pneumonia (CMS readmission-penalty diagnoses) in 14 acute care hospitals in Texas. The program, designed for scalable delivery, incorporated identification of high readmission-risk patients, assessment of individual needs, medication reconciliation, discharge planning, care coordination, and telephonic postdischarge follow-up.
  
  
  METHODS
  The treatment group of program enrollees (N = 560) and the comparison group with no program contact (N = 3340) were matched on 8 coarsened demographic, diagnosis, and severity variables associated with readmission risk. Assessed outcomes included relative risk and odds of readmission within 30 days postdischarge and overall within the 6-month evaluation period. Zero-inflated Poisson multivariate models were used to estimate intervention effects controlling for matching-generated weights, age, disease status, and period of evaluation.
  
  
  RESULTS
  Treatment group risk of readmission was 22% lower overall (incidence rate ratio [IRR], 0.78; P < .01) and 30-day readmission risk was 25% lower (IRR, 0.75; P = .01) relative to the comparison group. Odds of any or 30-day readmission were 0.47 (95% CI, 0.35-0.65) and 0.56 (95% CI, 0.41-0.77), respectively, for treatment relative to comparison.
  
  
  CONCLUSIONS
  Participation in the CTS resulted in significantly lower rates of readmissions among patients with readmission-sensitive conditions, offering a scalable and sustainable approach to reduce the number of preventable hospital readmissions.
authors.forename: Brent
authors.initials: B
authors.lastname: Hamar
authors.affiliation: Healthways, Inc, 701 Cool Springs Blvd, Franklin, TN 37067. E-mail: elizabeth.rula@healthways.com.
authors.forename: Elizabeth Y
authors.initials: EY
authors.lastname: Rula
authors.forename: Aaron R
authors.initials: AR
authors.lastname: Wells
authors.forename: Carter
authors.initials: C
authors.lastname: Coberley
authors.forename: James E
authors.initials: JE
authors.lastname: Pope
authors.forename: Daniel
authors.initials: D
authors.lastname: Varga
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D008297:Male; D059065:Medication Reconciliation; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000453:epidemiology; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment; D013781:Texas / Q000453:epidemiology; D000069341:Transitional Care / Q000458:organization & administration*; D055815:Young Adult