Effects of the Care Transition Intervention in the PCMH on Heart Failure 30 Day Readmissions

Eileen M German, Thomas Jefferson University


Heart failure (HF) is the leading cause of hospitalization for Medicare patients, and an estimated 25% of these patients are readmitted to the hospital within 30 days. There are multiple causes for these readmissions, mostly related to the complex medical and social histories, which put the Medicare population at high risk. To address the complexity of this population, hospitals have implemented a multitude of initiatives with varying results. The Patient Centered Medical Home (PCMH) has been identified as an ideal mechanism to improve patient care coordination and continuity of care through the transitional care management intervention (TCMI). The TCMI includes post-discharge communication within 2 days of discharge, follow-up appointment within 7–14 days, medication reconciliation, education, adherence assessment, and referrals for needed services. The first part of the study compared the characteristics of the PCMH patients to the non-PCMH patients, as well as 30-day readmission outcomes. The bivariate logistic regression analysis identified predictors of 30 day unplanned all cause readmissions. The comorbidity renal failure and days from discharge to first visit were the main statistically significant predictors of 30-day readmissions. Although patients receiving TCMI had a lower readmission percentage, it did not prove to be statistically significant for the patients receiving the intervention in the PCMH practices. The second part of the study was to examine the practice level factors that might predict a v30-day readmission. Linear regression was utilized to examine the relationships between the practice level predictors and 30-day readmissions. None of the predictors were found capable of predicting 30-day readmissions. Hierarchical linear modeling was utilized to explore the effects of the practice level factors (practice size, panel size, average readmission rate and quality rating), on PCMH patients and how they varied across patient populations. The low Intraclass Correlation Coefficient (ICC) identified that membership in a PCMH practice accounted for only 1% of the total variance that would explain why HF patients were readmitted in 30 days. Overall, the study was able to identify patient level predictors of 30-day readmissions. The TCMI resulted in a lower percentage of readmissions for HF patients than for those HF patients that did not receive the intervention.

Subject Area

Medicine|Public health|Health care management

Recommended Citation

German, Eileen M, "Effects of the Care Transition Intervention in the PCMH on Heart Failure 30 Day Readmissions" (2018). ETD Collection for Thomas Jefferson University. AAI10785418.