Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

James E. Bailey, Satya Surbhi, Jim Y. Wan, Kiraat D. Munshi, Teresa M. Waters, Bonnie L. Binkley, Michael O. Ugwueke, Ilana Graetz

Research output: Contribution to journalArticlepeer-review

19 Scopus citations


Background: Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. Objective: To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. Design: Quasi-experimental study. Patients: Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. Interventions: The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. Main Measures: Primary difference‐in‐differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30‐day readmissions, and hospital days), and medical expenditures. Key Results: Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (− 0.40; 95% confidence interval (CI), − 0.73 to − 0.06), 31% fewer 30-day readmissions (− 0.34; 95% CI, − 0.61 to − 0.07), and reduced medical expenditures ($− 8690; 95% CI, $− 14,441 to $− 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, − 39.1% to 72.9%). Conclusions: Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Original languageEnglish
Pages (from-to)1815-1824
Number of pages10
JournalJournal of General Internal Medicine
Issue number9
StatePublished - Sep 15 2019

Bibliographical note

Funding Information:
The project described was supported by Grant Number ICIMS 331067-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. In addition, this work was partially supported by the University of Tennessee Health Science Center and the Robert S. Pearce Endowed Chair in Internal Medicine.

Publisher Copyright:
© 2019, Society of General Internal Medicine.


  • Medicaid
  • Medicare
  • care transitions
  • chronic disease
  • health care delivery
  • multiple chronic conditions
  • quality improvement
  • super-utilizer
  • underserved populations

ASJC Scopus subject areas

  • Internal Medicine


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