Transitional programs can help reduce hospital readmissions

Hospitals can reduce readmissions with good transitional and follow up care, according to two studies in the Archives of Internal Medicine.

In the first study, researchers recruited a sample of fee-for-service Medicare patients to receive the Care Transitions Intervention, where interventions were implemented by a dedicated coach, and included a hospital visit, two follow-up phone calls, and a home visit.  The findings showed that patients in the program had an average 12.8% 30-day hospital readmission rate, compared with a 20% readmission rate for patients not in the program.

In the second study, nurses led interventions for heart failure patients, which included one home visit before discharge, and at least eight visits in the three months after discharge.  The nurse was available by telephone 7 days a week.  The results showed that the intervention significantly reduced adjusted 30-day readmission rates by 48% during the postintervention period.  However, the intervention had little effect on length of stay or total 60-day direct costs under the current fee-for-service model.

(Sources: The Advisory Board Daily Briefing,, July 26, 2011; The Archives if Internal Medicine,, July 2011)