Impact of an Integrated Transition Management Program in Primary Care on Hospital Readmissions

• DOI: 10.1097/01.jhq.0000460119.68190.98
• Publication Date: 2016-05-12T11:34:32Z
• Authors: Timothy W. Farrell; Andrada Tomoaia-C...; Debra L. Scammon; Kimberly Brunisholz; Jaewhan Kim; Julie Day; Lisa H. Gren; Stephanie Wallace; Karen Gunning; Jennifer Tabler; Michael K. Magill
• Keywords: Medical Home; Hospital Readmission; Vulnerability; Transitional care; Medication Reconciliation; Integrated Care

Poorly executed transitions in care from hospital to home are associated with increased vulnerability adverse medication events and readmissions, also excess healthcare costs. Efforts improve coordination on discharge have been shown reduce readmission rates but often rely interventions that not fully integrated within the primary setting. The Patient Centered Medical Home (PCMH) model, whose core principles include posthospital setting, is an approach addresses a more fashion. We examined impact of multicomponent transition management (TM) services time among 118 patients enrolled TM program part Care By Design, University Utah Community Clinics' version PCMH. conducted retrospective analysis comparing outcomes for before receiving same after services. all-cause 30-day rate decreased 17.9% 8.0%, mean 180 days was delayed 95 115 days. These findings support effectiveness activities