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The American Journal of Managed Care May 2018
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Rural Hospital Transitional Care Program Reduces Medicare Spending
Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
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Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
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Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
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Olena Mazurenko, MD, PhD; Jay Shen, PhD; Guogen Shan, PhD; and Joseph Greenway, MPH
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Kim Ekblom, MD, PhD, and Annika Petersson, MSc, PhD

Rural Hospital Transitional Care Program Reduces Medicare Spending

Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
A telephonic transitional care program at a rural hospital reduced postdischarge Medicare spending by 31% and reduced inpatient spending for Medicare fee-for-service beneficiaries.
ABSTRACT

Objectives: To evaluate impacts of a telephonic transitional care program on service use and spending for Medicare fee-for-service beneficiaries at a rural hospital.

Study Design: Observational cohort study.

Methods: Patients discharged from Atlantic General Hospital (AGH) with an AGH primary care provider were assigned a nurse care coordinator for 30 days. The nurse reviewed the patient’s conditions, assessed needs for transition support, conducted weekly telephone calls (beginning 24-72 hours after discharge) to monitor adherence to treatment plans, and scheduled follow-up appointments. Using claims data, we evaluated impacts on service use and spending using a difference-in-differences design with a matched comparison group.

Results: The intervention reduced Medicare spending in the 6-month period after discharge by 30.8%, or $1333 per beneficiary per month (90% CI, –$2078 to –$589), which was partly driven by a 39.4% reduction in spending for inpatient claims (difference, –$729; 90% CI, –$1234 to –$225). There were no statistically significant changes in the 14-day ambulatory care follow-up rate, 30-day unplanned readmission rate, number of inpatient admissions, or number of emergency department visits, although this may be due to modest statistical power to detect effects.

Conclusions: The estimated $5.4 million in savings from this intervention more than offset the costs of the $1.1 million funding for the award. Although other studies have found that care transitions programs can improve outcomes, this study was unique in the size of the impacts relative to the low-touch intervention and the location in a small rural healthcare system.

Am J Manag Care. 2018;24(5):256-260
Takeaway Points

A telephonic transitional care program at a rural hospital reduced postdischarge Medicare spending and inpatient spending for Medicare fee-for-service beneficiaries.
  • Healthcare decision makers seek to identify ways to deliver better healthcare at lower costs to beneficiaries with high healthcare needs, including patients recently discharged from a hospital.
  • Small rural community-based hospitals have the ability to reduce posthospitalization spending and healthcare use.
  • The estimated $5.4 million in savings from this transitional care program well exceeded CMS’ $1.1 million costs for the award.
  • This promising program model merits further testing.
CMS seeks to identify ways to deliver better healthcare, improve health, and lower costs for beneficiaries of its programs, particularly those with the highest healthcare needs.1 One promising approach toward achieving this goal is transitional care, which encompasses a range of services provided to patients as they transfer across settings or levels of care to improve outcomes and avoid preventable hospitalizations, readmissions, and emergency department (ED) visits.2 Transitional care interventions vary in the populations they target, the services they provide, the types of providers delivering services, and the duration of support. Intervention components typically include patient or caregiver education, discharge planning, scheduling postdischarge appointments, monitoring a patient’s condition and adherence to the discharge plan, medication reconciliation, and coordination among health professionals involved in the transition.3-5

Prior studies have found that care transitions programs can improve patients’ outcomes.4-7 However, there is limited evidence on which interventions work best in different settings,3,4 and transitional care interventions at stand-alone community hospitals might not always achieve their goals.8 Further, lower rates of follow-up care and greater risk of ED visits for postdischarge Medicare beneficiaries in rural settings, compared with urban beneficiaries, highlight the need for policies that increase follow-up care in rural settings.9,10 Testing of transitional care programs in rural settings is needed.4

This study examined how a telephonic transitional care intervention for patients discharged from the hospital affected service use and Medicare spending in a small rural healthcare system.

METHODS

Using an observational cohort design, we evaluated the intervention’s effects on service use and spending among Medicare fee-for-service (FFS) beneficiaries using difference-in-differences (DID) design with a matched comparison group.

Setting

Atlantic General Hospital (AGH) is a private, not-for-profit, community-based healthcare delivery system with a 62-bed hospital and 7 primary care practices. AGH is located in Worcester County, Maryland, a largely rural county and a federally designated medically underserved area. Although the hospital is located in a resort area, most of AGH’s primary care patients live there year-round. AGH program administrators note that many residents are older than 65 years and have low levels of literacy.

Intervention

In July 2012, AGH received $1.1 million in Health Care Innovation Award (HCIA) funding from CMS’ Center for Medicare & Medicaid Innovation (CMMI) to implement a patient-centered medical home model that included a care transitions program.11 The program aimed to reduce 30-day readmissions and healthcare costs and targeted patients discharged from AGH who had any diagnosis and an AGH primary care provider (PCP). The program employed 1 full-time nurse care coordinator with extensive clinical and case management experience who managed a caseload of 40 to 50 patients at any given time.

The nurse monitored the hospital’s daily census to identify eligible patients. Using AGH’s electronic health record system, the nurse reviewed patient information, including reason for the hospital stay, recent primary care visits, and discharge instructions, and notified the patient’s AGH PCP of the admission. The nurse visited patients in the hospital to describe the program and identify postdischarge needs. She later called patients at home within 24 to 72 hours of discharge to enroll them in the program. (Participation was voluntary; 10% of patients opted out or could not be reached by phone after 3 tries.) During the initial call, the nurse reviewed the patient’s conditions, reconciled medications and identified barriers to medication compliance, identified immediate needs for support and barriers to self-care, and scheduled follow-up appointments with the AGH PCP. Thereafter, the nurse called participants weekly to monitor their conditions and compliance with postdischarge treatment plans. Participants with unstable conditions based on the nurse’s clinical judgment or who needed additional support received more frequent calls to address emerging needs in a timely manner. In rare cases, the nurse contacted the participant’s PCP regarding urgent needs and coordinated additional office visits or referrals. Patients left the transitional care program within 30 days after discharge from the hospital.


 
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