Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: A Quasi-Experimental Study

James E. Bailey
Satya Surbhi
Jim Y. Wan
Kiraat D. Munshi
Teresa M. Waters
Bonnie L. Binkley
Michael O. Ugwueke
Ilana Graetz
Peer-Reviewed Article
July 2019

This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs.

  • 285 participants were enrolled in SafeMed, an intensive interdisciplinary care transition intervention, and 1950 served as concurrent controls.
  • The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.
  • Participation in the program was associated with 7 percent fewer hospitalizations, 31 percent fewer 30-day readmissions, and reduced medical expenditures over six months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39 percent in emergency department visits, 25 percent in hospitalizations, and 79 percent in 30-day readmissions.
  • Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among Medicaid patients with complex needs.
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