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Invited Commentary
September 2018

Transitional Care Management Services for Medicare Beneficiaries—Better Quality and Lower Cost but Rarely Used

Author Affiliations
  • 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
  • 2Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California
JAMA Intern Med. 2018;178(9):1171-1173. doi:10.1001/jamainternmed.2018.2545

“Come back and see us soon” is not what hospital staff say to patients these days. With policy makers and insurance payers taking aim at the high readmission rates of recently discharged patients, hospitals and clinicians have increasing financial incentives to manage the transition of care for patients from inpatient medical facilities back to the community. Successful patient interventions typically include multiple components, such as readmission risk assessments, discharge planning, medication reconciliation, follow-up appointment scheduling, patient education, coaching by dedicated clinicians, home health visits, and prompt follow-up visits with outpatient physicians.1 A recent meta-analysis of 50 multicomponent, quality improvement interventions found that readmissions fell by a mean of 12.1% among patients with heart failure and 6.3% among older adults.2

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