This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs.
- 285 participants were enrolled in SafeMed, an intensive interdisciplinary care transition intervention, and 1950 served as concurrent controls.
- The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.
- Participation in the program was associated with 7 percent fewer hospitalizations, 31 percent fewer 30-day readmissions, and reduced medical expenditures over six months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39 percent in emergency department visits, 25 percent in hospitalizations, and 79 percent in 30-day readmissions.
- Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among Medicaid patients with complex needs.
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Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
- What are the effects of transitional care programs for patients with complex needs on quality, outcomes, and costs?
- What is an example of a promising program?
Level of Evidence
StrongWhat does this mean?