Home Health & Hospice Week

A Medicaid transitional care program that includes home visits has reduced hospital readmissions by 20 percent, according to a study published in the Health Affairs journal.

"In 2008 North Carolina initiated a state-wide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions," says the study abstract. "In a study of patients hospitalized during 2010–11, we found that those who received transitional care were 20-percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care."

In the program, care managers typically talked to high-risk patients in the hospital and followed up with a home visit within 72 hours after discharge, the Raleigh News & Observer newspaper reports. At the patient’s home, the care manager reviewed the patient’s prescriptions with the patient and family and made sure the patient kept doctor’s appointments. "In some cases, the manager arranged transportation, even accompanying the patient to the doctor’s office," the newspaper notes.

"In the absence of this kind of support, the majority of these highest-risk patients will be rehospitalized within three months," said the study’s lead author, C. Annette DuBard with Community Care of North Carolina. "We can be confident this is a positive return on investment because so many readmissions were averted."

The study abstract is at http://content.healthaffairs.org/content/32/8/1407.