Edria Hoff, RN, BSN*1;Mary White, RN1;Jennifer Grande1;Diane Anderson1;Kim Couch1;John Larkin, MS2;Marta Reviriego-Mendoza, PhD2;Len Usvyat, PhD2;Laki Gajic, RN, BSN1;Jocelyn Ludwick1;Keriann Barnett-Howell, MPH1;Marina Farah, MD, MHA1 and Michael Radzienda, MD1, (1)Sound Physicians, Tacoma, WA, (2)Fresenius Medical Care North America, Waltham, MA

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 249

Categories: Research Abstracts, Transitions of Care


Background: National readmission rates for all-cause hospitalizations are as high as 14 readmits per 100 index admissions and have been relatively unchanged for at least the last 5 years (Fingar K, et al. Agency for Health Care Policy and Research, 2015). Since January of 2013, the Centers for Medicare & Medicaid Services has adopted a new payment bundle for Transitional Care Management (TCM) services to reward providers for taking an active role in providing better care coordination across the healthcare continuum. We have piloted a TCM initiative at two hospitals in the Sound Physicians hospitalist organization with the aims of improving the transition of acutely ill hospitalized patients back into the community. Overall, the goals of the program were to improve the rates of 30 day readmissions, the patient experience, and the care provided by the heath system.


In January of 2015, we implemented a TCM pilot in two hospitals that included the provision of transitional care from the day of discharge to 30 days post-hospitalization by developing a TCM nurse practitioner (NP) role and a checklist. By doing so, we expected to navigate patients through their post-hospital experience and appropriately link them with resources prior to and after discharge, including assessment of risk for hospital readmission and patient education. In this program, we enhanced the relationships with post-acute partners, caregivers, primary care physicians, and ancillary service providers through the provision of: 1) interactive patient telephone or e-mail contact within 2 business days of discharge, 2) physician medication reconciliation, lab/radiology review, and hospital course review with the patient, 3) a home or office visit with a TCM NP within 7-14 days of discharge, and 4) TCM NP consultation with, and handoff to the outpatient providers.


In the first month of the pilot program, 470 patients were provided with TCM. Overall, from before to after the implementation of the TCM, we observed decreases in the 30 day all-cause readmission rates of 3.7% in one hospital and 7% in the second hospital. Through the initiation of this pilot, we identified barriers with manual patient tracking and billing process, which prompted technology development to address these areas.


Addition of a TCM program and nurse practitioner role was effective in reducing 30 day all- cause readmission rates after discharge of acutely ill hospitalized patients and improved the coordination of care across the healthcare continuum. With the use of standardized checklists and procedures, as well as, implementation of technology for patient tracking and billing process, this initiative has been designed to be scalable, making it of high importance to the leadership of hospitals and hospitalist systems.

To cite this abstract:

Hoff, E; White, M; Grande, J; Anderson, D; Couch, K; Larkin, J; Reviriego-Mendoza, M; Usvyat, L; Gajic, L; Ludwick, J; Barnett-Howell, K; Farah, M; Radzienda, M . IMPLEMENTING A HOSPITAL BASED TRANSITIONAL CARE MANAGEMENT INITIATIVE REDUCES READMISSION RATES. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 249. Journal of Hospital Medicine. 2017; 12 (suppl 2). Accessed April 1, 2020.

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