[Skip to Content]
[Skip to Content Landing]
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

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×