Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital

TLDR

The Coordinated‑Transitional Care (C‑TraC) program was created to enhance care coordination and outcomes for high‑risk veterans discharged to community settings. Patients receive phone‑based support from nurse case managers who manage medication reconciliation and other care issues before and after discharge. The program reduced rehospitalizations by about one‑third and generated an estimated net savings of $1,225 per patient, while requiring only modest resources and being suitable for rural or resource‑constrained settings.

Abstract

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.