Transitions of Care - The Path to Readmission Reduction

In 2018, Door County Medical Center (DCMC) implemented Transitions of Care Management (TCM) for Medicare patients only. Through the COVID pandemic, readmission rates increased significantly and were occurring for many non-Medicare patients within 30-days of discharge. In July 2021, DCMC implemented an expanded TCM program to cover all adults regardless of payor source. In addition to one phone contact and follow-up visit post-discharge, an in-hospital visit was added. This service was also provided for the full 30-days post-discharge. The patient experience, elements of TCM, preventive practices, and diagnosis-specific support were the methods implemented. As a result, all cause readmissions decreased from 5.4% to 3.9% over a period of 12 months. As of March 2023, all cause readmission rate has reduced to 3.1%.