Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among patients with high-risk conditions discharged to community settings from the hospital. Patients in the C-TraC program experienced one-third fewer rehospitalizations than those in the comparison group and there was an estimated savings of $1,225 per patient. This model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or constrained resources. A toolkit with the C-TraC protocol is available on HIPxChange here.

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