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A new study reveals that a statewide transitional care program in North Carolina reduced readmissions risk for Medicaid patients by 20% in the subsequent year.
For the study -- believed to be the largest of its kind in the nation -- researchers looked at Medicaid patients discharged from North Carolina hospitals between 2010 and 2011. They looked at more than 13,000 patients with chronic complex conditions who enrolled in the program, and compared the rate of readmission with those of 8,000 patients who did not enroll in the program. It included 120 hospitals across the state, and all but one of the state’s counties.
Eight hundred nurses and social workers did intensive follow-up with patients, sometimes following them for months. The nurses made sure patients had all their medications, understood and followed all instructions, and ensured patients made and kept their primary care physician appointments. The study’s lead author says that care managers would typically follow up at home with a patient within 72 hours after discharge to review discharge instructions with the patient and family, conduct medication reconciliation, and even drive the patient to his or her follow-up appointment if needed. The program prevented about one readmission for every six patients.
With 30-day readmissions penalties from CMS set to double next month, hospital systems and even states are looking for all ways possible to prevent readmissions. While the North Carolina model may not be feasible for all states or health systems, it certainly gives something to think about.