Hospital readmissions are a huge problem; in 2010 nearly one-fifth of discharged patients were readmitted, and one half of those readmissions were preventable. New Transitional Care Management codes incentivize physicians to improve care during the post-hospital period, with a follow up phone call in 48 hours and an office visit in 14 days. We developed a transition protocol for our hospitalized Family Medicine Residency Clinic patients, with the goal of decreasing 30-day readmission rates and emergency room visits. Secondary outcomes were to increase use of Transitional Care Management codes, and increase clinic revenue. Initial results show patients who completed the protocol had their 30-day readmission cut in half, and ED visit rates reduced by 6% with a number needed to treat of 16 and 25 respectively. Implemented widely, this approach could reduce readmissions in multiple specialties, improve continuity of care, and increase value by decreasing cost and improving quality.
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