Work

Testing the Patient-centered Medical Home Plus Transitional Care Model

Year: 2017

Type: conference-abstract

Abstract: The Patient-Centered Medical Home (PCMH) and the Transitional Care Model (TCM) are among the few care management approaches that have targeted chronically ill adults and demonstrated improvements in multiple dimensions of patients’ health, while decreasing costs. With the guidance a multi-stakeholder advisory group including nationally recognized experts and in collaboration with partnering primary care clinicians, a PCMH+TCM intervention was designed and pilot tested. 54 patients were enrolled in the PCMH+TCM group and 25 patients enrolled in the PCMH only group. Data on patient outcomes and resource use were collected at enrollment, 1-, 3-, 6- and 12-months. Propensity score weighted mixed effects and Cox proportional hazard models were used to compare the PMCH+TCM vs. PCMH only groups on outcomes. The PCMH+TCM group demonstrated improvements in emotional health (decreased depression) and quality of life over time when compared to the PCMH only group. For a subset of patients with hospitalizations in the 30 days prior to enrollment (N=36), the PCMH+TCM group (n=15) had a longer time to first rehospitalization than the PCMH only group (n=21). 25% of the PCMH+TCM group were rehospitalized by day 228 vs. day 27 for the PCMH only group. The hazard of being rehospitalized in the PCMH+TCM group was 40% lower than the PCMH only group. While the effect size was strong, small sample sizes influence the power to detect statistically significant differences. Findings from this pilot suggest that this co-management care model can improve patient reported outcomes and reduce costly resource use among at-risk, community-dwelling older adults.

Source: Innovation in Aging

DOI: 10.1093/geroni/igx004.2769