Further Proof That Transitional Care Works for Medicaid Patients

Research on Medicaid patients in North Carolina validates with data what we've known anecdotally for some time: Transitional care works, both to improve population health, and to save money.

Many studies examining the value of transitional care contain an obvious "Duh!" factor.

It's not a radical concept: If you follow up on patients post-discharge, make sure they're following a treatment plan, going to physicians' appointments, taking their medications, changing risky behaviors, etc., then it's less likely they'll be readmitted into the hospital.

Who knew! Get me rewrite!

Sarcasm aside, there is a lot of value in these seemingly obvious findings. They validate with statistics what common sense screams out and what we've known anecdotally for some time: Transitional care works, both to improve population health, and to save money.

A study out of North Carolina and published in Health Affairs makes that point on a statewide scale. Researches with Community Care of North Carolina, a public-private collaborative to coordinate care in the state, wants to reduce readmissions among high-risk Medicaid patients with chronic conditions. The study examined the medical records of about 13,000 Medicaid patients from across the state in a transitional program and who were hospitalized in 2010-11.

Their readmissions were compared with those of 8,000 Medicaid recipients who received little if any transitional care. The study found that patients in the transitional care program were 20% less likely to be readmitted in the following year and that one readmission was avoided for every six patients in transitional care, including one in three of the highest-risk patients, the study found.

"In terms of this being a 'no brainer,' one of the biggest things that this study adds to the literature is that it's becoming more and more evident that transitional care is effective," says Carlos Jackson, lead author of the study, and director of program evaluation at Raleigh-based CCNC.

"There are a number of randomized studies that show that the intervention is effective, but those studies are on a small scale in a very controlled setting. What is unique about our study is we were able to bring this to an entire statewide program, and that is very unusual. We are talking about an entire state, multiple healthcare systems and providers, different settings, different regions of the state with very different issues; being able to disseminate it in that way and actually show that it is effective. There is a lot of good stuff that has been shown to be effective on a small scale in a very controlled randomized study but when you try to roll it out into large scale program sometimes some of the effectiveness drops off. What was unique is that we could show that 'hey we are just as effective when we go statewide.'"

Reducing 30-day readmissions is hot topic in hospitals these days now that Medicare has attached financial penalties to the statistic. Jackson says it's only a matter of time before Medicaid carries the same stick.

"Certainly 30-day readmissions are the topic of the day and everybody is working to reduce it, not just in their Medicare population," he says. "You will find that when you start changing processes in your hospital or practice that you are going to have spillover to your entire patient population. As you do these handoffs better, hopefully you will be impacting more than just your Medicare population."

The North Carolina study did not include a cost-benefit analysis of transitional programs, although Jackson concedes that "that is the question everybody wants answered."

"What we say in our paper and what is true is that we can be fairly confident that there is a positive return on investment if you just do the math," he says. "When you do transitional care with just six patients you can prevent one admission in a year. Each admission costs $6,000. As long as that is higher than what it costs to manage those six patients for a relatively brief period of time in transitional care, it is a positive return on investment."

Why does transitional care work? Again, common sense provides obvious answers. If you make sure that the patient is following discharge instructions, taking medications, seeing his physician in an out-patient setting, monitoring chronic conditions, etc., of course there will be a better outcome.

However, Jackson says it's harder to pinpoint exactly why transitional care works on a larger scale. "That is a very challenging question to answer because the transitional care program is tailored to the individual," he says.

"If you have a patient who doesn't have a lot of needs, they only need a little support. Whereas somebody who is high risk and high need you have to give them a lot of support. Sometimes in the evaluation it may show that that person you have given a lot of support to still shows up back at the hospital but maybe you've kept them in the hospital a little bit longer. Those kinds of things are hard to tease out."

Anecdotally, Jackson believes that a key component of transitional care is the home visit by a medical professional. "A lot more comes out in the home. You learn a lot more than you would with a phone call," he says. "They are telling you one thing, but you clearly see that they are not. Maybe there are mobility issues, transportation issues, there may be environmental or nutrition or health issues. A picture paints a thousand words."

Jackson says patients appreciate the voluntary home visit too. "They like having the extra support and having a nurse come and check in on you and make sure you are OK and have what you need," he says. "They love the clarification and the support they need when they come out of the hospital."

Let's review: Transitional care reduces readmissions, improves patient outcomes, saves money, and engages patients to become an active partner in their own care plan. With every new study, the statistics and other objective evidence are lining up behind the common sense.