Transitional Care Management Visits to Improve Coordination of Care

AJMC April 12, 2021
Sajana K. Patel, MPH, Andrew Miller, MD, MPH, Sue Chen, MS, Andrew Lindsay, MPH, Melody Gray, BSN, RN, CCM, Ya-Ping Su, PhD

Inspira Care Connect, LLC, an accountable care organization, incorporated transitional care management services into its postdischarge follow-up process to prevent avoidable utilization of health care services and costs.

ABSTRACT

Objectives: This report aimed to determine whether transitional care management (TCM) services, provided by Inspira Care Connect, LLC (ICC), a Track 1 Medicare Shared Savings Program accountable care organization, were effective in reducing 30-day readmission rates, observation stay days, and emergency department visits, along with mortality rates, total costs, and frequency of primary care physician (PCP) visits among Medicare beneficiaries served by ICC.

Study Design: In accordance with TCM programming, ICC contacted the majority of patients telephonically within 48 business hours after discharge from an inpatient setting and scheduled a face-to-face...

Today's Sponsors

Today's Sponsor