With funding from a Centers for Medicare & Medicaid (CMS) Health Care Innovation Award, Truman Medical Centers (TMC) developed a care transitions program that led to 283 fewer hospital admissions, 845 fewer emergency department (ED) visits, and more than $3 million in costs savings over the course of a year among 198 socially and medically complex patients.
The patients in this program are commonly referred to as high-cost high-utilizing patients. They suffer from multiple chronic diseases, such as diabetes and hypertension, and frequently return to the hospital or ED after discharge due to social issues, such as a lack of housing or food insecurity.
Our health care system has long struggled to improve care and reduce costs among socially and medically complex patients. This makes TMC’s work all the more remarkable and worthy of being featured in the July/August 2015 issue of the Journal for Healthcare Quality (PDF download).
Patients Are Enrolled Until They “Graduate”..
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