Health System Intervention Cut Readmission Risk by 22 Percent

Results in the current issue of The American Journal of Managed Care show that Texas Health Resources, in collaboration with Healthways, put a care transitions program into 14 hospitals that sharply reduced readmissions through collaborative discharge planning and follow-up.


PLAINSBORO, N.J.—An intervention of patient education and discharge planning in a group of Texas hospitals sharply cut hospital readmissions, according to results published this month in The American Journal of Managed Care.

Texas Health Resources, a faith-based, nonprofit health system, collaborated with Healthways, a well-being improvement company, to deliver the intervention, known as Healthways Care Transitions Solution® (CTS). The intervention was implemented in 14 acute care hospitals over a six-week period in 2013. The full article can be found here.

The treatment program enrolled 560 patients, whose results were compared with 3,340 patients who had no contact with the program. Patients were followed for six months. The intervention featured personalized education, individual follow-up by phone, and care coordination to ensure that patients made it to medical appointments after leaving the hospital.

Results showed that the treatment group had a 22 percent overall reduced risk of readmission, and a 25 percent reduced risk of 30-day readmission, the figure that is closely watched by the Centers for Medicare and Medicaid Services for reimbursement.

“A focus on reducing hospital readmissions—which contribute to overall hospitalization rates—is recognized as an opportunity to improve care while also reducing avoidable costs,” write the authors, led by Brent Hamar, DDS, MPH and Elizabeth Rula, PhD.

The authors note that the CTS model benefits both patients and the hospital by maximizing “cost efficiency and scalability through sophisticated prediction of high-risk cases for selective supplemental support and by outsourcing program operations, data management, predictive modeling, and post-discharge telephonic follow-up.”

CMS’ focus on 30-day readmission rates followed a 2004 study that showed 20 percent of fee-for-service Medicare patients returned to the hospital within a month, costing taxpayers $17.4 billion a year. A program to reduce readmissions followed, and hospitals that cannot reduce readmission rates face penalties. More recently, CMS has acknowledged that hospitals treating high numbers of low-income patients need overcoming barriers to discharge planning and effective post-acute care.

About the Journals and

The American Journal of Managed Care is the leading peer-reviewed journal dedicated to issues in managed care. distributes healthcare news to leading stakeholders across a variety of platforms. Other titles in the franchise include The American Journal of Accountable Care, which publishes research and commentary on innovative healthcare delivery models facilitated by the 2010 Affordable Care Act. AJMC’s Evidence-Based series brings together stakeholder views from payers, providers, policymakers and pharmaceutical leaders in oncology and diabetes management. To order reprints of articles appearing in AJMC publications, please call (609) 716-7777, x 131.

Related Videos
View All
Related Content
© 2023 MJH Life Sciences
All rights reserved.