Transitional Care Management: Direct Impact on Reduction in Readmission Rate
The Richland Hospital and Clinics are dedicated to preventing readmissions, a goal shared by many organizations. In collaboration with the Wisconsin Hospital Association, the Wisconsin Office of Rural Health, and other peer organizations, they sought advanced techniques to minimize readmission rates. In 2023, The Richland Hospital and Clinics successfully implemented Transitional Care Management (TCM) for discharged patients, maintaining a readmission rate of around 6.5% throughout the year.
The improvement project focused on key areas: identifying high-risk patients, scheduling follow-up appointments based on case complexity, and expanding the TCM program. To enhance the program, the team participated in educational sessions and strengthened collaboration and communication between inpatient units and the TCM team. Monthly data tracking and sharing allowed for continuous improvement and plan adjustments.
The efforts quickly revealed a direct correlation between the TCM team's work and the reduction in readmissions. This success emphasized the importance of early identification of readmission risk and the necessity for patients to attend follow-up visits. The organization continues to expand the program, recognizing the critical role of early intervention and ongoing patient care in reducing readmissions.
