• James E Bailey, Satya Surbhi, Jim Y Wan, Kiraat D Munshi, Teresa M Waters, Bonnie L Binkley, Michael O Ugwueke, and Ilana Graetz.
• Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA. jeb@uthsc.edu.
• J Gen Intern Med. 2019 Sep 1; 34 (9): 181518241815-1824.

BackgroundMany health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.ObjectiveTo determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.DesignQuasi-experimental study.PatientsAmong 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.InterventionsThe 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.Main MeasuresPrimary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.Key ResultsAdjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).ConclusionsCare 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 high-need, high-cost Medicaid patients.

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