Successful Transition Care Management/Care Coordination Programs

  • At the Veteran’s Administration in Madison, WI, the Transition Care Program yielded an 11% reduction in readmissions which avoided 409 inpatient days, saving $966,000 in 18-months.
  • A national healthcare company achieved a 23% reduction in readmissions with their Transitional Care Management (TCM) program.
  • Two University of Pennsylvania randomized controlled trials on nurse-led hospital discharge and home follow-up programs for chronically ill older adults showed 30-50% reductions in readmissions and net savings in costs of $4,000 per patient.

The Transitional Care Model uses an advanced practice registered nurse who meets with patients and family during hospitalization to devise a care plan for managing their chronic disease.  Together, they set goals by examining the cause for their instability and addressing these in a plan, coordinating care providers and services.  The nurse visits the home soon after discharge and provides phone and in-person follow-up for up to three months.  Nurse led counseling and attending doctor appointments have helped them learn the early warning signs of a problem and better manage their care.

To provide oversight of the overall plan of care, having a primary care provider was found to be a key factor.(TCM Developer: Dr Mary Naylor, NewCourtland Center for Transitions & Health, University of Pennsylvania (

In three randomized controlled trials on Medicare beneficiaries with multiple chronic illnesses, TCM lengthened the period between discharge and readmission or death and reduced hospital readmissions. The average annual savings was $5,000 per patient (Naylor, 1994; Naylor et al., 1999, 2004).

This retrospective cohort study found that telephone outreach to ensure patient understanding of and adherence to discharge orders following a hospitalization reducing hospital readmissions by 23% within 30 days after discharge. These findings indicate that timely discharge follow-up by telephone to supplement standard care is effective at reducing near-term hospital readmissions and, thus, provides a means of reducing costs for health plans and their members (Population Health Management 2011 Feb;14(1):27-32. doi:10.1089/pop.2009.0076. (E-publication) 2010 Nov 19.The impact of postdischarge telephonic follow-up on hospital readmissions. Harrison PL, Hara PA, Pope JE, Young MC, Rula EY).

Startling Stats

US healthcare expenditures skyrocketed to $3 trillion in 2014 and may rise to $5 trillion by 2022; three quarters of these expenditures is due to top 6 chronic diseases (source: Center for Medicare and Medicaid Services).

This healthcare burden will grow as our population ages:

  • Nearly 10,000 baby-boomers turn 65 years old each day.
  • Nearly 1 of every 2 adults has at least one chronic illness;
  • 26% live with multiple chronic diseases, and this is expected to grow .

The encouraging news is that minimal changes in unhealthy behaviors could delay onset of or prevent chronic diseases to reduce these costs  (Ross DeVol and Armen Bedroussian, An Unhealthy America; the Economic Burden of Chronic Disease, Charting a New Course to Save Lives and Increase Productivity and Economic Growth, Santa Monica, Calif.; Milken Institute, 2007). (Milken Institute slide show )

Medication Adherence

Poor medication adherence costs our nation $300 Billion.

When patients fail to take their medications according to the prescribed dosage, time, frequency, and direction, serious side effects and complications may occur.  Research shows:

  • 50% of all patients do not take their medications as prescribed;
  • more than 1 in 5 new prescriptions are not filled;
  • patients with chronic conditions have the lowest adherence.

Poor medication adherence results in 33% to 69% of medication-related hospital admissions (Osterberg L, Blaschke T, “Adherence to Medication,” NEJM., 2005;353(5):487-497).
Total potential savings from adherence and related disease management could be $290 billion annually — 13% of health spending.
(Source: NEHI Research Brief, “Thinking Outside the Pillbox: A System-wide approach to Improving Patient Medication Adherence for Chronic Disease.” NEHI, 2009.)
For each additional $1.00 spent on high cholesterol medications there was $5.10 saved in care costs; for high blood pressure medications, $3.98 saved in care costs (

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