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03.07.2019 | Original Research

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

Journal of General Internal Medicine
MD James E. Bailey, PhD Satya Surbhi, PhD Jim Y. Wan, PhD Kiraat D. Munshi, PhD Teresa M. Waters, MA Bonnie L. Binkley, DHA Michael O. Ugwueke, PhD Ilana Graetz
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s11606-019-05082-8) contains supplementary material, which is available to authorized users.

Prior Presentation

Preliminary results of this study were presented in abstract form as a poster presentation entitled “Cost Savings Associated with Participation in the Safemed Program, an Innovative Care Transitions Program for Super-Utilizers with Multiple Chronic Conditions” at the Academy Health Annual Research Meeting in Minneapolis, MN, June 15, 2015, by Bailey JE, Graetz I, Munshi KD, Surbhi S, Wan JY, and Waters TM. These preliminary results have been referenced in several subsequent presentations and in SafeMed toolkits (co-branded by the American Medical Association and the Society of General Internal Medicine) available at www.​stepsforward.​org/​modules/​safemed-transition-care and at www.​SafeMed.​org.

Publisher’s Note

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Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.


To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.


Quasi-experimental study.


Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.


The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

Main Measures

Primary difference‐in‐differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30‐day readmissions, and hospital days), and medical expenditures.

Key Results

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (− 0.40; 95% confidence interval (CI), − 0.73 to − 0.06), 31% fewer 30-day readmissions (− 0.34; 95% CI, − 0.61 to − 0.07), and reduced medical expenditures ($− 8690; 95% CI, $− 14,441 to $− 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, − 39.1% to 72.9%).


Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

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