RESUMO
BACKGROUND: Transitional Care Management (TCM) is a reimbursable service designed to minimize hospital readmissions. We describe a multifaceted approach to increase TCM services among 107 primary care providers in a rural catchment area of 4250 square miles. OBJECTIVE: The primary objective was to increase use of TCM phone calls, office visits, and billing codes; the secondary objective was to decrease hospital readmissions. METHODS: We utilized a learning health system model, an improvement support team (IST), and a learning collaborative that included webinars and in-person support. The process emphasized user-centered system redesign, coaching, electronic health record (EHR) improvements, and real-time feedback. Analyses included statistical process control charts, box plots, analysis of variance, and t-tests. RESULTS: The IST engaged stakeholders to design and test TCM workflows and EHR prototypes. This resulted in rapid, iterative improvements and system-wide spread of new processes. In the month following implementation, TCM calls and visits quadrupled and increased during 18 subsequent months. Pragmatically, most discharged patients (95% in a subsample) did not receive both the TCM call and visit, serving as a comparison group. The Readmission rate for patients receiving complete TCM services was 5.0% (n = 101) versus 11.9% for comparators (n = 2103, P = .03). Billing codes increased initially, then returned to baseline. CONCLUSIONS: Our approach led to rapid, sustained scaling of TCM calls and visits in a rural primary care group. Patients who received TCM calls and visits had significantly fewer readmissions. Training of new staff, including PCPs, is required for sustainability. Future research is warranted to increase adoption and evaluate additional outcomes including mortality rates, patient satisfaction, and health care economics.