- Published in American Journal of Managed Care -

Impact of a Scalable Care Transitions Program for Readmission Avoidance

Author(s): Brent Hamar, DDS, MPH; Elizabeth Y. Rula, PhD; Aaron R. Wells, PhD; Carter Coberley, PhD; James E. Pope, MD; and Daniel Varga, MD

AJMC_01_2016_-_Cover-194321-edited.jpg 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: The treatment group of program enrollees and the comparison group with no program contact 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 post-discharge and overall within the 6-month evaluation period.

ResultsTreatment group risk of readmission was 22% lower overall and 30-day readmission risk was 25% lower relative to the comparison group. Odds of any or 30-day readmission were 0.47 and 0.56, 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.

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Topics: Health Conditions Health Plan & Health System Medical Costs & Utilization Predictive Modeling Science and Research Care Transitions Solution