The use of transitional care may reduce the number of rehospitalizations for complicated chronic conditions, according to a study from North Carolina. Researchers found that implementing interventions such as bedside visits before discharge, home care visits by a care manager and medication reconciliation were less likely to get readmitted in the next year compared with patients with similar medical problems receiving usual care.

“Patients with multiple chronic conditions are known to receive fragmented care involving multiple clinicians, take multiple medications, have increased risk for hospital admissions, and contribute disproportionately to overall health care costs,” wrote the authors, led by Carlos T. Jackson, PhD, of Community Care of North Carolina in Raleigh. Community Care of North Carolina is a community-based program designed to provide physician-led coordinated care for patients throughout the state.

The state began implementation of transitional care for these high-risk patients in 2008. The program emphasizes thorough medication management, patient education on managing their conditions and timely follow-up after discharge with a fully-informed medical home.

In their study, published in the August issue of Health Affairs, the authors followed 21,375 Community Care of North Carolina patients with complex chronic conditions receiving Medicaid for one year who had a hospital discharge between July 2010 and June 2011. There were 13,476 who received transitional care assessments, while the others received usual care.

“Adjusted readmission rates were approximately 20 percent lower for Medicaid beneficiaries who received transitional care within thirty days of discharge than for clinically similar beneficiaries who received usual care,” the researchers found. The highest-risk patients derived the most benefit.

Broken down further, they found that one of every six patients who received transitional care avoided readmission. Among the patients most at risk, one in three were able to avoid rehospitalization.

The researchers noted that previous studies have yielded similar results, including research on transitional care among Medicare patients with comparable medical conditions.

There could be a number of reasons why this agency’s transitional care program is successful. One, the authors hypothesized, is because the program facilitates coordination of care that may not be feasible in smaller practices that often serve the state’s Medicaid patients.

The next step, the authors concluded, is to examine how to ensure patients continue to benefit from transitional care.

“Future research is needed to evaluate the factors that may be associated with successful implementations of such interventions. These factors may include variations in community, hospital, and practice characteristics related to program implementation, as well as variations in network staffing and processes,” they wrote.