Systematic Review of Ambulatory Transitional Care Management (TCM) Visits on Hospital 30-Day Readmission Rates

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

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


To reduce readmission rates and prevent adverse outcomes after discharge, hospitals have begun implementing “transitional care” initiatives. This systematic review identifies research on the particular set of services now reimbursable by Medicare (transitional care management [TCM]) and evaluates the studies for program effectiveness. Results of 3 databases were screened for peer-reviewed journal articles published between January 2004 and 2015 that report on readmissions of adults in the US health care system under the Medicare TCM bundle. was queried for funded studies. Of 969 identified studies, 77 met inclusion criteria for relevance to transitional care and appropriateness of population and setting. Of these, only 3 articles incorporated all required elements for TCM service. Although 2 were program improvement designs and none were randomized controlled studies, each report reduced readmission rates. Evidence for TCM effectiveness is limited. Additional study of TCM implementation and programmatic support for TCM is warranted.

Original languageEnglish
Pages (from-to)19-26
Number of pages8
JournalAmerican Journal of Medical Quality
Issue number1
StatePublished - Jan 1 2017

Bibliographical note

Publisher Copyright:
© 2015, © The Author(s) 2015.


  • 30-day readmission
  • chronic disease
  • systematic review
  • transitional care

ASJC Scopus subject areas

  • Medicine (all)


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