Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates

Am J Med Qual. 2018 Nov/Dec;33(6):583-589. doi: 10.1177/1062860618775528. Epub 2018 May 10.


A process improvement initiative for transitional care management (TCM) was evaluated for effectiveness in reducing 30-day readmission rates in a retrospective cohort study. Regression models analyzed the association between level of TCM component implementation and readmission rates among patients discharged from a university medical center hospital. Of the 1884 patients meeting inclusion criteria, only 3.7% (70) experienced a 30-day readmission. Patients receiving the full complement of TCM had 86.6% decreased odds of readmission compared with patients who did not receive TCM ( P < .001). However, the complete package of TCM services under Medicare guidelines may not be essential. A postdischarge telephone call did not reduce readmission odds, provided a TCM office visit occurred. Important for risk assessment models targeting patients for TCM, the number of previous hospital admissions, not age, predicted 30-day readmission risk. This study provides evidence that primary care-based TCM can reduce 30-day readmissions even when overall rates are low.

Keywords: 30-day readmission; ambulatory care; patient-centered medical home; transitional care management.

MeSH terms

  • Academic Medical Centers
  • Adult
  • Aged
  • Ambulatory Care*
  • Female
  • Humans
  • Kentucky
  • Male
  • Middle Aged
  • Patient Discharge
  • Patient Readmission / trends*
  • Patient-Centered Care
  • Retrospective Studies
  • Transitional Care*