Utilization of transitional care management services and 30-day readmission
2025

Impact of Transitional Care Management on 30-Day Readmissions

Sample size: 11391 publication 10 minutes Evidence: high

Author Information

Author(s): Kim Eun Ji, Coppa Kevin, Abrahams Sara, Hanchate Amresh D., Mohan Sumit, Lesser Martin, Hirsch Jamie S.

Primary Institution: Northwell Health

Hypothesis

Does the type of post-discharge follow-up visit affect 30-day readmission rates?

Conclusion

Transitional care management visits are associated with lower 30-day readmission rates compared to non-TCM visits.

Supporting Evidence

  • TCM follow-up visits were associated with an 8.4% readmission rate compared to 13.9% for non-TCM visits.
  • Being seen by a provider who frequently uses TCM visits reduced the odds of readmission.
  • Patients with TCM visits had a hazard ratio of 0.46 for readmission compared to non-TCM visits.

Takeaway

Patients who have follow-up visits after leaving the hospital are less likely to return to the hospital within 30 days, especially if they have a special type of follow-up called transitional care management.

Methodology

A cross-sectional analysis using data from Northwell Health to compare 30-day readmission rates between patients with TCM and non-TCM follow-up visits.

Potential Biases

Potential underrepresentation of patients who had follow-up visits outside the health system.

Limitations

The health system database may not capture all out-of-network follow-up visits, and some patients may have been contacted within 48 hours without documentation.

Participant Demographics

Adult patients hospitalized to Medicine service, aged 21 and older.

Statistical Information

P-Value

<0.001

Confidence Interval

0.39–0.55

Statistical Significance

p<0.001

Digital Object Identifier (DOI)

10.1371/journal.pone.0316892

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