Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

Health Aff (Millwood). 2012 Dec;31(12):2659-68. doi: 10.1377/hlthaff.2012.0366.


The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Continuity of Patient Care / organization & administration*
  • Cost Savings*
  • Female
  • Health Care Surveys
  • Hospital Costs
  • Hospitals, Veterans
  • Humans
  • Length of Stay
  • Male
  • Nurse Administrators / economics
  • Nurse Administrators / statistics & numerical data*
  • Nurse-Patient Relations
  • Patient Discharge / statistics & numerical data
  • Patient Readmission / economics
  • Patient Readmission / statistics & numerical data*
  • Program Evaluation
  • Telenursing / economics*
  • United States
  • Wisconsin