Trauma Transitional Care Coordination: A Mature System at Work

Background We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination Program (TTCC) in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations. Methods TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission (HSCRC) database to collect data on statewide unplanned 30-day readmissions. Results 475 patients were enrolled in the TTCC program from January 2014 to September 2016. Only 11% (n=50) of TTCC enrollees were privately insured, 60% had Medicaid (n=259), and 13% had Medicare (n=64). 73% had HSCRC severity of injury (SOI) ratings of 3 or 4 (maximum SOI = 4). The most common All Patient Refined Diagnosis Related Groups (APR-DRG) for participants were: lower extremity procedures (n=67, 14%); extensive abdominal/thoracic procedures (n=40, 8.4%); musculoskeletal procedures (n=37, 7.8%); complicated tracheostomy and upper extremity procedures (n=29 each, 6.1%); infectious disease complications (n=14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n=13 each, 2.7%). TTCC participants with lower extremity injury, complicated tracheostomy, and bowel procedures had 6-point (10% vs 16%, p=0.05), 11-point (13% vs 24%, p=0.05), and 16-point (11% vs 27%, p=0.05) reduction in 30-day readmission rates respectively compared to those without TTCC. Conclusion Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower extremity injury, complicated tracheostomy and bowel procedures. This represents over one million dollars savings for the hospital per year through quality based reimbursement. Level of Evidence Level III, Epidemiological Corresponding Author: Erin C. Hall MD MPH, MedStar Washington Hospital Center, Washington DC, erin.c.hall@medstar.net, Pager: 202-801-1340 There are no conflicts of interest to report. Presented at the 76th Annual Meeting of the American Association for the Surgery of Trauma, September 12th, 2017 in Baltimore MD © 2018 Lippincott Williams & Wilkins, Inc.

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