Key result
The virtual-first Transition to Home program successfully reduced both 30- and 90-day rehospitalization rates among >8,000 patients discharged from 68 participating hospitals.
Why the study?
Despite the proven effectiveness of evidence-based transitional care, hospitals and health systems often struggle to scale and sustain postdischarge transitional care programs.
Does a virtual-first, interdisciplinary transitional care program reduce 30- and 90-day rehospitalization rates in patients discharged from hospitals participating in alternative payment models?
Observational (n=8,000)
Yes
Does a virtual-first, interdisciplinary transitional care program reduce 30- and 90-day rehospitalization rates in patients discharged from hospitals participating in alternative payment models?
A rapidly scaled, virtual-first transitional care program successfully reduced 30- and 90-day rehospitalizations for patients discharged from hospitals in alternative payment models.
Supports virtual transitional care in value-based models; leaves open need for RCTs to confirm causality.
SummaryReducing unnecessary readmissions to acute care hospitals is a key lever of success in many advanced alternative payment models. Despite the proven effectiveness of evidence-based transitional care, hospitals and health systems often have difficulty scaling and sustaining postdischarge transitional care programs. As the United States' largest convener of Medicare's Bundled Payments for Care Innovation Advanced (BPCI-A) program, Signify Health implemented and rapidly scaled a virtual-first, evidence-based, interdisciplinary transitional care program now serving patients in 15 states. In the first 12 months since its inception on February 1, 2021, the Transition to Home (TTH) program has coordinated care for more than 8,000 patients discharged from 68 hospitals participating in either BPCI-A or an ACO. By focusing on care plan review, facilitating access to home- and community-based services and supports, and reconnecting patients with their primary care and specialty providers, the TTH program has successfully reduced both 30- and 90-day rehospitalization rates. Early challenges included language barriers, documentation for proxy decision-making, and excessive precall preparation time.
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Rothman et al. (2022) conducted an observational in Hospital discharge (n=8,000). Transition to Home (TTH) program was evaluated on 30- and 90-day rehospitalization rates. The virtual-first Transition to Home program successfully reduced both 30- and 90-day rehospitalization rates among >8,000 patients discharged from 68 participating hospitals.
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