Care Transition Management and Patient Outcomes in Hospitalized Medicare Beneficiaries

AJMC September 19, 2024
Mariétou H. Ouayogodé, PhD, Brianna Hardy, BS, Mariétou H. Ouayogodé, PhD, Brianna Hardy, BS, John Mullahy, PhD, Maureen A. Smith, MD, PhD, MPH, Ellen Meara, PhD

Hospital care transition activity facilitates uptake of Medicare-reimbursed transitional care management, which is associated with lower spending and better patient outcomes.

ABSTRACT

Objectives: To assess whether discharging hospitals’ self-reported care transition activities (CTAs) were associated with transitional care management (TCM) claims following discharge to the community and whether CTAs and TCM were associated with better patient outcomes.

Study Design: Cross-sectional study of 424,115 hospitalized Medicare fee-for-service beneficiaries 66 years and older who were discharged to the community in 2017 and attributed to 659 hospitals in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate, 46.5%). Of these beneficiaries, 76,156 were categorized into a Hospital Readmissions Reduction Program (HRRP) cohort based on admission principal diagnoses.

Methods: Using logistic regression,...

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