The Transitional Care Model significantly decreased the number of re-hospitalizations (45 vs. 60 events, P<0.041) and total hospital days at 3 months compared to a matched control group.
Does the Transitional Care Model improve health outcomes and reduce healthcare utilization and costs in chronically ill older adults?
Implementation of the Transitional Care Model in a real-world Medicare Advantage population significantly reduced short-term re-hospitalizations and 1-year healthcare costs.
Absolute Event Rate: 29% vs 38.7%
p-value: p=< 0.041
OBJECTIVE: To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness. METHODS: A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year. RESULTS: Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0. 041) and total hospital days (252 vs. 351, P < 0. 032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of 439 per member per month in total health care costs at 3 months and cumulative per member savings of 2170 at 1 year (P < 0. 037). CONCLUSIONS: Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.
Naylor et al. (Wed,) conducted a other in chronically ill older adults with acute episodes of illness (n=310). Transitional Care Model (TCM) vs. matched control group was evaluated on number of re-hospitalizations at 3 months (p=< 0.041). The Transitional Care Model significantly decreased the number of re-hospitalizations (45 vs. 60 events, P<0.041) and total hospital days at 3 months compared to a matched control group.