A new study of a transitional care model that relies on nurses talking weekly with recently discharged hospital patients finds that the program reduces readmission rates and saves money.
The study by a team of Wisconsin-based researchers examined the Coordinated Transitional Care program, in place at a Veterans Administration hospital in Madison, Wisconsin. The authors write, "Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients [in the program] experienced one-third fewer re-hospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs."
"The nurse engages the patient in an open-ended discussion," beginning within 72 hours of discharge from the hospital, said lead investigator Amy Kind, MD, PhD. "They spend a lot of time talking about medications, follow-up and the appropriate response to any signs and symptoms that the patient’s medical symptoms could be worsening…. Many patients, within two days of discharge, were not taking their medications properly,” she continued. “They may not have understood what they should have been doing, or became confused about their medications when they arrived home. Our nurse can help them work through those issues and make sure they are doing things as they should.”
The authors conclude that the program requires a "relatively small amount of resources to operate," and suggest that it might be particularly useful for providers in rural areas or in care settings facing resource constraints. The study was published in the December issue of Health Affairs.