A new report took a deeper dive to see if the Center for Medicare & Medicaid Services’ transitional care management (TCM) program is reaching those most at risk. Even though the program is designed to reach people at risk for readmission, the authors said that the population is less likely to receive the service.
The TCM program began in 2013 to oversee coordination of care coordination and reduce readmission in the first 30 days after hospital discharge. Uptake has been slow but steady, but researchers weren’t sure if it’s reaching people at a high risk for readmission, such as those with dementia or people who are frail.
The report published Thursday in Journal of the American Geriatrics Society evaluated the utilization rate of the service according to characteristics that are linked to higher risk for readmissions. The team looked at factors such as demographics, diagnosis at discharge and frailty index.
The researchers took a random sample of 5% of the Medicare fee-for-service claims between 2015 and 2019. A total of 1,556,347 eligible discharges were included. The average age of participants was 78.3 years old and 56.7% were female.
Eligible discharges came from short-term hospitals, psychiatric hospitals, skilled nursing facilities, psychiatric hospitals, observational stays or partial hospitalizations. All of the data was from people who were 65 and older. Then researchers ran models on the data.
TCM was delivered in 10.9% discharges, and 30-day readmission happened in 8% of discharges. People who were less than 75, Black or Hispanic, and those who were frail and had dementia were less likely to receive TCM. People were also less likely to receive TCM if they were dually eligible for Medicare and Medicaid, or discharged from medical facilities other than short-term hospitals.The authors acknowledged some limitations in their research. The team didn’t have data on participants’ social determinants of health and practice-level characteristics that may have played a role in TCM use.
