A transition care coordinator model reduces hospital readmissions and costs

Abstract

Background:The optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention.Methods: A quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N=7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only).

A Scoping Review on How to Make Hospitals Health Literate Healthcare Organizations

“…In the literature, it is clear that limited health literacy is a significant factor associated with increased healthcare utilization and costs [126,127], and that meeting the needs of people with limited health literacy could produce savings of approximately 8% of the total costs for this population [127]. However, only three studies [40,80,98] reported "costs" as an outcome. Health organizations need resources and strategies to save staff time and costs [128].…”

Health-Literate Healthcare Organizations and Quality of Care in Hospitals: A Cross-Sectional Study Conducted in Tuscany

“…The importance of HL has not only been recognized in terms of health outcomes, but also in terms of economic results [11]. The instruments to increase HL levels are considered "inexpensive and easy to implement", but at the same time, capable of reducing costs and improving outcomes in terms of disease prevention [12,13] by means of increased adherence to potentially life-saving screening [14], decrease in hospitalization rates [15,16], and appropriate use of healthcare services [17].…”

PH Professional Network: Bridging the Gap: A Multidisciplinary Approach to Transitions of Care

“…Clearly, education prior to discharge reduces readmissions and associated health care cost. 16 Nurses and allied health personnel are critical to the success of patient education.…”

“…20 Home nursing visits, nursing case management including structured telephone support, and follow up in specific disease management clinics have been shown to decrease readmissions compared with usual care. 16 Structured telephone follow up after hospital discharge by a nurse clinician is a simple, cost-effective method of assessing patient status and wellbeing, reviewing key discharge education and instructions, and identifying issues that may lead to poor outcomes. 21 This may address numerous concerns in a high-risk population and should be implemented ideally within 48 hours of discharge.…”