Policy and value-based payment models promote the importance of managing transitions of care.
Historically, hospitals were the primary focus of Medicare’s Hospital Readmissions Reduction Program (HRRP). However, consider that one in five Medicare beneficiaries is readmitted to the hospital within 30 days, and a high percentage of these readmissions are considered preventable.
They cost the US healthcare system about $17 billion annually. Beyond cost, research has shown that 30-day readmissions are an independent risk factor for all-cause mortality that persists for at least two years.
Despite hospitals lowering 30-day readmission rates for Medicare patients from 20% to 17.8%, care coordination between the acute setting and primary care providers is an essential next step in quality improvement.
Compelling research highlights the value of improved Transitional Care Management (TCM) for improving overall post-hospitalization mortality.
Here are studies that point to the value of managing transitions of care through this program within a primary care setting:
Engaging patients with primary care-based TCM maximizes the role of ambulatory care for improving post-hospitalization outcomes.
Research has demonstrated several strategies that support an effective primary care-based TCM program to reduce not only 30-day readmissions, but throughout post-discharge follow-up.
Past research wondered whether primary care physicians influenced readmission rates. However, one study found there was little variation among primary care physicians.
The Merit-based Incentive Payment System (MIPS) attempted to incentivize readmission reduction through a pay-for-performance program. However, MIPS has not been sufficient to motivate primary care practices to embark on a TCM program focused solely on hospital readmissions.
The government may step up efforts to put performance measures in place for primary care physicians. But, until there’s additional financial value and care quality built into the equation, it will be slow to get primary care on board.
Value-based care is a natural tie-in for TCM as one of several care management programs offered by Medicare.
TCM services consist of three segments—interactive contact, non-face-to-face services and an office visit with a physician responsible for the transition. All three elements are mandatory within TCM-specific timeframes, unless determined otherwise.
In addition to value-based care arrangements, primary care practices can be more competitive in health plan and system negotiations with a TCM program in place. Ambulatory care teams make more attractive partners by demonstrating value-added services that streamline care coordination.
Providing TCM services can also impact other performance measures by avoiding costly readmissions, exacerbations and poorer health outcomes.
Consider starting a new TCM program with a focus on patients who have diagnoses that are included in the HRRP program, such as:
This could be scaled to other conditions as needed over time.
Studies have shown that primary care practices have a shorter window to impact readmission risk.
Quality signals were highest on the first day after discharge and declined rapidly until they reached a nadir at seven days. The study found similar patterns across states and diagnoses.
Additionally, research has shown that after seven days, a primary care practice’s impact, ergo responsibility, essentially decays. After the seventh day post-discharge, readmissions were explained by community- and household-level factors beyond the hospital’s, or primary care practice’s control.
Primary care leaders should consider strategies that connect with patients and family caregivers before discharge and engage immediately after. This window provides the best opportunity to support the transition, avoid readmission and set a path for better health.
Providers that track patient hospitalizations and offer TCM early in the patient’s hospital course have been found to be vital.
Clinical staff should facilitate TCM by:
Practices with an established TCM program can proactively educate patients and their families about hospital readmissions.
Providing resource materials, an after-hours phone number or contact portal enables patients and their caregivers to reach out upon readmission. This helps the care team prepare for what the patient will need throughout their next transition of care.
Primary physician–based transitions of care have received less emphasis in healthcare. But successful hospital-based programs engage more deeply with post-discharge ambulatory services. Working collaboratively, inpatient and outpatient transition teams have been shown to have the best outcomes when post-discharge contact utilizes multiple components.
Clinic-based care managers may be a primary point of contact via phone calls, medication reconciliation, addressing transportation barriers and scheduling with social workers and other care team members.
Narrowly focused TCM programs, conversely, were less effective.
Most readmission reduction efforts have been focused on hospital efforts for Medicare beneficiaries. A 2020 report by the Agency for Healthcare Research and Quality (AHRQ report), emphasized the role and value of including primary care.
However, another AHRQ-funded report focuses on evidence-based strategies to reduce readmissions for adults enrolled in Medicaid.
Both approaches rethink primary care's role in preventing hospital readmissions by acting as an “integrator” within the larger health ecosystem. This fits well with value-based care initiatives and models, such as Making Care Primary.
TCM that is adapted for adult Medicaid beneficiaries would put primary care in a critical position for post-discharge patient care, including:
There are many points of value for primary care along the inpatient-to-outpatient journey.
TCM provides a reimbursable model that reduces readmissions and delivers value-based care and performance measures, leading to better post-admission healing and long-term health outcomes.
ThoroughCare helps deliver integrated care management services to foster patient engagement and enhance revenue. Our platform provides the digital infrastructure to leverage fee-for-service programs while promoting value-based care objectives.
ThoroughCare supports end-to-end workflow for TCM, including: