Purchaser & Policymaker
"At AARP we're very aware of the fact that there's a growing number of us who are aging... Health care is a big part of our concern. Models like TCM are practical, applied models that can make a difference today."
Jennie Chin Hansen, President-Elect, AARP, Washington, DC
Reducing Avoidable Hospitalizations
The Transitional Care Model (TCM)
The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. The heart of the model is the Transitional Care Nurse (TCN), who follows patients from the hospital into their homes and provides services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use, and prevent health status decline. While TCM is nurse-led, it is a multidisciplinary model that includes physicians, nurses, social workers, discharge planners, pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care. For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management - all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient's physicians.
Background
Rehospitalization is prevalent, extremely common among the chronically ill and elderly populations, and expensive to the health care system. Studies have estimated readmission rates to be in excess of 25% with the majority of rehospitalizations occurring in the first three months.1 In a recent analysis of the 616,000 Medicare beneficiaries discharged from U.S. hospitals in 2005 with a diagnosis of heart failure, 27% were readmitted within 30 days, 39% within 60 days and almost 50% within 90 days.2
Studies like these have been followed by closer examination of readmission rates by public payers and policymakers. In 2007, the Medicare Payment Advisory Commission (MedPAC), the independent Congressional agency established to advise the U.S. Congress on issues affecting the Medicare program, estimated that nearly 18% of Medicare beneficiaries admitted to a hospital are readmitted within 30 days of discharge, with an even higher rate among beneficiaries with multiple chronic conditions. MedPAC calculated that this "churning" of patients accounts for an estimated $15 billion in spending. These findings led MedPAC to encourage public reporting of hospital readmission rates, payment reform to financially encourage lower readmission rates, and the adoption by hospitals of readmission-reducing strategies.3
MedPAC's recommendations have resulted in a swift cascade of policy reforms. The Centers for Medicare & Medicaid Services (CMS) recently emphasized reducing readmission rates through its Quality Improvement Organization (QIO) Program, transparency initiatives (e.g., publicly reporting of 30-day risk standardized readmission rates for heart failure), and value-based purchasing activities (e.g., proposed incentives to hospitals and home health providers to reduce avoidable readmissions). TCM is a tested solution to these growing policy concerns.
1Friedman B, Basu J. The rate and cost of hospital readmission for preventable conditions. Med Care Res Rev. 2004; 61(2):225-240
2Personal Communication with Stephen Jencks, MD, MPH, Centers for Medicare & Medicaid Services based on MedPar (Medicare hospital claims) data.
3MedPAC. Promoting Greater Efficiency in Medicare. Washington, DC: MedPAC; June 2007.