Transitional Care Management Associated With More Healthy Days At Home, Lower Spending After Hospital Discharge.

Abstract

Since 2013, Medicare has reimbursed clinicians for delivering transitional care management (TCM) services after patients' discharge from eligible medical facilities. Concurrently, Medicare has implemented population-based Alternative Payment Models (APMs) to encourage patient-centered care, care coordination, and clinician accountability. In this analysis, we used 2017-20 Medicare data to evaluate the effect of TCM on four quality and cost outcomes and the effect of population-based APM participation on the association between TCM and the four outcomes. TCM was associated with more healthy days at home and lower total spending after hospital discharge, with more pronounced differences among patients aligned with population-based APMs compared to nonaligned patients. TCM was also associated with lower readmissions but not differences in mortality; neither finding varied between patients who were versus were not aligned with population-based APMs. These findings suggest that the benefits of TCM may be even greater when patients are aligned with population-based APMs, highlighting potentially complementary effects.