Findings from three NIH funded, multi-site RCTs have consistently demonstrated positive economic outcomes including significant decreases in time to first readmission, total number of hospital readmissions, inpatient days, and total health care costs.i In one study, patients in the TCM spent less than half as many days in the hospital as control group patients, suggesting the value of the model in improving post-discharge outcomes.ii The most recent RCT, demonstrates that patients in the TCM experienced 36% fewer readmissions through 52 weeks post-discharge with an estimated mean per-patient savings in total health care costs of about $5,000.i
Enhanced care management and supportive services by TCM providers has resulted in fewer rehospitalizations for these patients’ primary illnesses as well as their coexisting conditions. Additionally, among those patients who required rehospitalizations, the time between their primary discharge and readmission was longer and the number of inpatient days was shorter than among their non-TCM counterparts.
As stated above, the Transitional Care Model has demonstrated decreases in hospital readmissions and inpatient days. In addition, patients who have received care under the TCM model showed improvements in physical function, and patient safety.
While the Kaiser Permanente study is not complete, anecdotal evidence suggests that nurse satisfaction is high. Individual nurses reported higher levels of job satisfaction in the role of the Transitional Care Nurse than in their previous nursing roles. The nurses enjoyed spending more one-on-one time with the patient and being able to follow-through with the patient. One nurse noted, “We have moved from being part of the problem to being part of the solution.”
Patient and Family/Caregiver Satisfaction
Improvements in overall quality of life, physical aspects of quality of life, and patient satisfaction have been reported among patients receiving care under TCM. Furthermore, family members, who are most likely to be burdened by these patients’ care needs, have reported experiences of lower caregiving demands and higher family functioning.
iNaylor, M.D., et al. “Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial” Journal of the American Geriatric Society, Volume 52, pp 675-684, 2004.
iiNaylor, M.D., et al. “Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders” Journal of the American Medical Association, Volume 281 Number 7, pp.613-620, 1999.