Transitional care interventions: Evidence supports more intense interventions

Jan. 8, 2016 / By L. Gordon Moore, MD

Responding to value-based-purchasing, provider groups across the US are implementing or tweaking programs to reduce unnecessary hospital readmission or emergency department visits. Much of this is stimulated by Medicare’s plans to move the bulk of their payment into new models and the current incentives around readmission reduction for beneficiaries with certain conditions.

Luckily for all involved, there is an increasing literature base guiding those who would like science to help their decision-making process.

Vedel and Khanassov’s meta-analysis of transitional care interventions provides some nice information to guide those developing programs to improve outcomes for people with congestive heart failure.¹

They classified interventions like this:

Gordon Moore interventions table

What they found:

  • Providing transitional care interventions to 52 people prevents one re-admission.
  • Providing transition care interventions to 9 people prevents one ED visit.
  • Low-intensity interventions do not improve results.
  • Moderate intensity interventions lasting longer than 6 months do have impact.
  • High- intensity interventions for less than 6 months have a positive impact.

Bottom line:

Telephone-only follow up has no impact on readmissions or ED visits in this meta-analysis of transitional care interventions. For a measureable impact on readmission rates, emphasis should be placed on moderate and high intensity interventions.

L. Gordon Moore, MD, is senior medical director for populations and payment solutions at 3M Health Information Systems.

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¹ Isabelle Vedel and Vladimir Khanassov, “Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis,” The Annals of Family Medicine 13, no. 6 (November 1, 2015): 562–71, doi:10.1370/afm.1844.