The program, begun in 2008, tracked readmissions and one-year readmissions rates for more than 21,000 patients with multiple chronic conditions statewide between 2010 and 2011.
Medicaid beneficiaries who were part of the transitional care program had 20 percent lower risk-adjusted readmission rates than those who did not receive transitional care.
Transitional care under the North Carolina program included steps customized according to each patient’s needs, including: transitional care need identification, a bedside visit prior to discharge, service coordination, medication reconciliation, a home visit by a nurse or nurse care manager and a pharmacist-completed comprehensive medication review.
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