• Sajana K Patel, Andrew Miller, Sue Chen, Andrew Lindsay, Melody Gray, and Ya-Ping Su.
• Quality Insights, 557 Cranbury Rd #6, East Brunswick, NJ 08816. Email: sajanakpatel@gmail.com.
• Am J Manag Care. 2021 Apr 1; 27 (4): e130-e134.

ObjectivesThis 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 DesignIn 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 visit with the patient's PCP within 1 to 14 days after discharge from an inpatient setting. The patients were provided with non-face-to-face services as needed throughout the 30-day period.MethodsThe effectiveness of the TCM model was measured using a retrospective propensity score matching design, which allowed for an accurate comparison between those who received TCM and similar ICC Medicare beneficiaries who did not. The analysis utilized Medicare parts A and B claims from January 1, 2016, to December 31, 2017.ResultsPatients who received TCM had lower 30-day readmission rates than those who did not (P < .05).ConclusionsThe services provided to ICC Medicare patients through the TCM model may have enhanced the ability to identify problems at an earlier stage, resulting in the prevention of complications and unnecessary utilization of costly health care services.

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