Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates

Jonathan Ballard, Wade Rankin, Karen L. Roper, Sarah Weatherford, Roberto Cardarelli

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


A process improvement initiative for transitional care management (TCM) was evaluated for effectiveness in reducing 30-day readmission rates in a retrospective cohort study. Regression models analyzed the association between level of TCM component implementation and readmission rates among patients discharged from a university medical center hospital. Of the 1884 patients meeting inclusion criteria, only 3.7% (70) experienced a 30-day readmission. Patients receiving the full complement of TCM had 86.6% decreased odds of readmission compared with patients who did not receive TCM (P <.001). However, the complete package of TCM services under Medicare guidelines may not be essential. A postdischarge telephone call did not reduce readmission odds, provided a TCM office visit occurred. Important for risk assessment models targeting patients for TCM, the number of previous hospital admissions, not age, predicted 30-day readmission risk. This study provides evidence that primary care–based TCM can reduce 30-day readmissions even when overall rates are low.

Original languageEnglish
Pages (from-to)583-589
Number of pages7
JournalAmerican Journal of Medical Quality
Issue number6
StatePublished - Nov 1 2018

Bibliographical note

Publisher Copyright:
© The Author(s) 2018.


  • 30-day readmission
  • ambulatory care
  • patient-centered medical home
  • transitional care management

ASJC Scopus subject areas

  • General Medicine


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