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Maccabi’s Transitional Care Program: Implications for promptness of follow-up, care coordination, service use and cost
Researchers: Bruce Rosen1, Chaled Abou-Hussein2, Bruce Landon3, Jack Zwanziger4
- Myers-JDC-Brookdale Institute
- Maccabi Health Services
- Harvard Medical School
- University of Illinois at Chicago
Background: Israel and other countries have increasingly recognized the importance of improved coordination of care as patients transition from hospitals to the community. Maccabi's Transitional Care Program (MTCP), which was introduced in 2015, is a large-scale effort to improve hospital-community coordination. Specially trained nurses contact Maccabi members who have recently been discharged from hospitals. The MTCP nurses assess the patients’ needs for follow up care and then arrange for those needs to be met through a wide variety of community-based providers.
Objectives: To assess the impact of the MTCP on promptness of follow-up, both re-admissions and the use of community-based services during the 30 days after discharge, and expenditures.
Method: The study’s main analysis used an intent to treat design to compare the outcomes of interest for patients discharged from the hospital prior to and after the program’s implementation. A secondary analysis focused on patients discharged in the 2016-7 period, comparing patients contacted by an MTCP nurse with those not contacted. Maccabi's extensive computerized patient records was the primary source of data for the study.
Findings: The study’s main approach found that the MTCP did not have programmatically or statistically significant effects on most of the key outcome variables. In contrast, the study’s secondary approach found substantial differences in key process and outcome measures between those contacted and those not contacted.
Conclusions: The study raises questions about the effectiveness of the MTCP program.
Recommendations: The findings suggest that if the program is to be continued, its targeting or protocols should be modified to increase its effectiveness. These changes might include ensuring that the contacts are made closer to the date of discharge and targeting the program on members over age 75 and members with multiple chronic illnesses.
Research number: A/92/2018
Research end date: 12/2020