title: Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates.
abstract: BACKGROUND
  Transitions of care from the hospital to the outpatient setting often fail to meet the Triple Aim of improving quality, improving the health of populations, and decreasing the cost of care. A major push to improve the quality of transitions and reduce hospital readmissions is under way.
  
  
  METHODS
  We implemented a team-based, transition-of-care model and assessed the impact on 30-day readmission rates. The 3 components of the intervention were contact with a nurse care manager, medication reconciliation, and follow-up with a physician. We compared 30-day readmission rates for the period before versus after implementation of this intervention.
  
  
  RESULTS
  The 30-day readmission rate decreased from 14.2% in the usual care group to 5.3% in the intervention group (P = .011). Almost 90% of patients in the intervention group received all 3 components of the intervention.
  
  
  CONCLUSIONS
  Generalizability is limited to practices with embedded team members. Not all patients received all 3 components of the intervention.
  
  
  CONCLUSIONS
  Development of a team-based intervention was associated with a significant reduction in hospital readmissions. This method could be implemented in other primary care offices with team-based care.
authors.affiliation: director of pharmacotherapy, Division of Family Medicine, Mountain Area Health Education Center, Asheville, North Carolina; assistant professor of clinical education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Bill.Hitch@mahec.net.
authors.forename: Bill
authors.initials: B
authors.lastname: Hitch
authors.affiliation: research project manager, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina.
authors.forename: Anna Beth
authors.initials: AB
authors.lastname: Parlier
authors.affiliation: physician, Division of Family Medicine, Mountain Area Health Education Center, Asheville, North Carolina.
authors.forename: Lisa
authors.initials: L
authors.lastname: Reed
authors.affiliation: director, Center for Research, Mountain Area Health Education Center; assistant professor, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Asheville, North Carolina.
authors.forename: Shelley L
authors.initials: SL
authors.lastname: Galvin
authors.affiliation: residency program director, Division of Family Medicine, Mountain Area Health Education Center, Asheville, North Carolina.
authors.forename: E Blake
authors.initials: EB
authors.lastname: Fagan
authors.affiliation: associate director of pharmacotherapy, Division of Family Medicine, Mountain Area Health Education Center, Asheville, North Carolina; assistant professor of clinical education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Courtenay Gilmore
authors.initials: CG
authors.lastname: Wilson
mesh_terms: D006801:Humans; D017146:Models, Organizational; D010346:Patient Care Management / Q000379:methods / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration*; D010359:Patient Readmission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000379:methods / Q000458:organization & administration; D011320:Primary Health Care / Q000379:methods / Q000592:standards; D015397:Program Evaluation; D058996:Quality Improvement; D000069341:Transitional Care / Q000592:standards*