Among high-risk patients receiving telephone-based transitional care management, 30-day readmission rates did not differ significantly between those with and without diabetes (22.9% vs 18.8%, P=0.525).
Observational (n=15,271)
No
Does a telephone-based transitional care management program reduce 30-day readmissions in high-risk patients with diabetes compared to those without diabetes?
A telephone-based transitional care management program in a rural setting showed no significant difference in 30-day readmissions between high-risk patients with and without diabetes.
Tasa de eventos absoluta: 22.9% vs 18.8%
valor p: p=0.525
Patient transitions from inpatient to home care are an important area of focus for reducing costly unplanned hospital readmissions. In rural settings, the challenge of reducing unplanned readmissions is amplified by limited access to both ambulatory and acute care as well as high levels of social disadvantage. In addition, there is a scarcity of evidence regarding strategies that have been proven to improve care transitions and related patient outcomes in this setting. This paper describes the process for implementation and results of a telephone-based transitional care management (TCM) program designed to reduce readmissions for patients with diabetes in a rural hospital in Scotland County, North Carolina. Data were collected from July 2016 to January 2019 using billing records to identify adult patients with high or very high risk of readmission based on length of stay, acuity, comorbidity, and emergency department visits (LACE) scores. Care managers contacted eligible patients by phone after discharge to review discharge instructions, assess need for home health services and transportation assistance, and schedule primary care follow-up visits. Overall, 13.8% of 15,271 discharges were targeted for TCM; 68.2% of these involved a patient with diabetes. The post-intervention 30-day readmission rate was 18.0% among patients identified as high or very high risk versus 8.8% among the overall population and did not differ significantly between TCM participants with diabetes and those without (22.9% vs.18.8%; P = 0.525). Findings highlight challenges with implementing transition of care interventions in rural settings, which include staffing, patient volume, and accessing data from out-of-network providers.
Taylor et al. (Mon,) conducted a observational in Diabetes and high risk of hospital readmission (n=15,271). Telephone-based transitional care management (TCM) vs. TCM participants without diabetes was evaluated on 30-day readmission rate (p=0.525). Among high-risk patients receiving telephone-based transitional care management, 30-day readmission rates did not differ significantly between those with and without diabetes (22.9% vs 18.8%, P=0.525).