Abstract
Patients living with chronic kidney disease (CKD) suffer significantly higher readmission rates after discharge than the national all-hospital 30-day rate. Federal-based programs have introduced payment models incentivizing prevention-oriented activities, like transitional care management (TCM) programs, that help patients safely transition from one care facility to their homes. In this quality improvement case study, we assessed our value-based kidney care organization's TCM clinical program, which empowers patients in their post-hospitalization journey by promoting increased awareness of their condition, adherence to medications, and care navigation, ultimately minimizing the likelihood of complications or readmission. CKD patients with moderate to high risk for readmission were included in the analysis. The findings demonstrated that enrollment in the TCM program reduced total hospital readmission rates compared to those who declined enrollment at 7-, 14-, and 30-days postdischarge (P < .01; 7-days, 42% lower; 14-days, 37% lower; 30-days, 25% lower). To reduce patient utilization and increase quality of care after a hospitalization, healthcare organizations should deploy a patient-centered transitional care approach in their care models.
Introduction
Chronic kidney disease (CKD) affects 14% of United States (US) adults yet represents 25% of Medicare spending in adults over 66. 1 CKD is often accompanied by various comorbidities that require additional care, leading to higher utilization and greater inpatient spend. In the US Medicare population, patients with CKD face a 30-day readmission risk of 21.7%. 2 Alarmingly, this rate surpasses the national all-hospital 30-day rate of readmission after discharge from hospital (14.6%) by a notable degree. 3
An estimated 10% to 21% of CKD-related hospitalizations are preventable and result from gaps in discharge planning. 4 Routine discharge plans lack proper patient engagement and understanding, leading to medication instruction confusion, inadequate support, provider disconnect, and incomplete follow-up. 5 These obstacles contribute to emotional hurdles, lower quality of life, and repeated hospitalizations. 6 Value-based care (VBC) models have created incentives to address these gaps, like stabilizing chronic diseases, timely intervention, and helping patients safely transition from the hospital through strong engagement, care coordination, and active monitoring.
Transitional care management (TCM) programs follow a patient-centered approach intended to deliver comprehensive care during the first 30 days post-discharge. The value-based kidney care organization in this study operates a TCM clinical program with a specialized care team following patients for 30-days post-discharge to alleviate patient readmission and financial burden. After 30 days, patients transition to a longitudinal care management (LCM) program for continuous care. This study aims to evaluate how our organization's TCM program contributes to lowering total hospital readmission rates.
Transitional care management program structure and processes.
Methods
A retrospective quality improvement case study was conducted to evaluate the effectiveness of our organization's ability to reduce the rate of total hospital readmissions at 7-, 14-, and 30-days post-discharge using claims data between November 2022 and June 2024. The cohort consisted of Medicare Advantage, Medicare Fee-for-Service, and Commercial patients aged 18 and older diagnosed with CKD stages 3 through 5. The study focused on patients who were admitted into an inpatient hospital facility and discharged home, where a proprietary algorithm utilizing patient characteristics, historical medical utilization, and attributes about the current discharge predicted a moderate or high risk of readmission (ie, > 0.50 probability of readmission). The treatment group consisted of patients who agreed to TCM during post-discharge outreach and received comprehensive follow-up management (weekly calls) and education on after-care instructions. The control group consisted of patients with similar levels of readmission risk who our organization was unable to contact or who declined TCM during post-discharge outreach.
Discharges included the total number of acute care related hospital admissions where patients were discharged home. Patients discharged to outpatient, long-term care, rehabilitation, or skilled nursing facilities were excluded. Readmission rates included the total number of discharges from the hospital, including instances where patients may have multiple discharges, and were calculated using the CMS Hospital-Wide All-Cause Unplanned Readmission Measure definition. 7 Medical claims were processed through the HCG Milliman Grouper and included the full 30-day follow-up period. To compare the rates of hospital readmissions between the treatment and control groups, chi-square tests were conducted, and the odds ratio was calculated for each follow-up time period (7-, 14-, and 30-day).
Ethical Considerations
Our organization does not require ethical approval for reporting individual quality improvement case studies.
What Encompasses the TCM Program?
Our organization constructed a multifaceted 30-day TCM program (Figure 1) focused on preventing readmission and removing barriers to care. The program models the Care Transitions Program, which provides tools for quality improvement and risk management and encourages active patient self-management, which has demonstrated lower hospitalizations.8–10-10 The TCM program is fully integrated into the broader care model and includes Registered Nurse Care Managers, Nurse Practitioners, Licensed Social Workers, Registered Dietitians, Medical Directors, and Care Coordinators. The team relies on the receipt of real-time admission, discharge, and transfer (ADT) feeds and authorization forms supplied by third-party vendors and health plans. Patients are contacted via telephone within 2 business days of discharge, with the third attempt at day 5, with weekly telehealth calls with the TCM team for 4 weeks thereafter. The team is available after-hours, weekends, and holidays through a 24/7 nurse line.
The program focuses on patient education surrounding their hospitalization, diagnoses, symptoms, and post-discharge needs. Education tools are tailored to individual needs, such as prevention and symptom checklists, comorbidities, lifestyle and diet, and treatment options. The TCM team evaluates and intervenes on barriers such as social needs, caregiver support, medication access and affordability, and access to care. TCM staff also coordinate follow-up appointments across care providers (Nephrologists, medical facilities, and specialists), verify appointment completion, and help patients understand visit summaries. By facilitating care coordination, patients are more likely to address concerns, adhere to care plans, and engage with providers, reducing the need for additional interventions.
Upon completing the 30-day program, patients “graduate” into LCM for continued chronic disease management and coordination, education on modality selection for optimal starts, behavioral health support, and/or dietary counseling. These wraparound services play a crucial role in empowering patients to engage in their care plan, improve patient experience, and lead to better quality outcomes, reducing the risk of hospitalization.
Results
A total of 2965 distinct patients met the inclusion criteria and were included in the final analysis, with a total of 4069 hospital discharges. While the TCM group had slightly higher proportions of less severe disease stages (P < .05), the overall prevalence of comorbid conditions was similar between TCM participants and non-participants. One exception was a slightly higher rate of congestive heart failure history in the control group (P < .05). However, based on the diagnosis codes billed for the initial hospital admissions, a greater proportion of TCM participants had a documented heart failure diagnosis (15.1%) compared to nonparticipants (13.3%) (Supplemental Table 1). The results showed that TCM participants experienced significant reductions in hospital readmissions at 7-, 14-, and 30-days post-discharge as compared to the control group (Table 1). The 7-day readmission rate was 3.0% versus 5.2% (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.37, 0.82; P < .01), resulting in a 42% reduction in hospital readmissions, the 14-day rate was 5.9% versus 9.3% (OR: 0.6; 95% CI: 0.45, 0.80; P < .001), resulting in a 37% reduction in hospital readmissions, and the 30-day rate was 12.1% versus 16.1% (OR: 0.72; 95% CI: 0.58, 0.88; P < .01), resulting in a 25% reduction in hospital readmissions. A total of 81% of the treatment group had a TCM initial assessment completed within the first 2 days of discharge, and 99% had an assessment completed within the first 7 days. TCM participants had an average of 2.6 clinician visits for CKD stage 3, 3.0 for stage 4, and 3.2 for stage 5 in the 30 days following discharge. This level of follow-up care reflects strong post-discharge support, indicating that early and active engagement can lead to more meaningful outcomes, as shown in these results. The significantly lower readmission rates highlight the influence that comprehensive, transitional care may have on reducing follow-up hospital utilization.
Significant Effect of TCM Program Enrollment on Rate of Hospital Readmission.
Total of hospital discharges were fewer than the minimum sample size requirements (n = 787 per group) to conduct statistical testing.
Includes disease management, care management, registered dietician, and social work visits during the 30-day postdischarge period.
Discussion
Patients with CKD experience disproportionately higher hospitalization rates, and guidance on post-discharge management strategies is needed to improve CKD outcomes. 11 Our TCM program supports the gap between inpatient and community settings through tailored early outreach, education, medication reconciliation, and timely follow-up. Our findings highlight significant reductions in readmission rates across CKD stages, suggesting personalized TCM interventions are remarkably effective in reducing readmissions.
Prior research stresses the need for comprehensive and holistic preventive programs post-discharge to minimize recurrent hospitalizations among CKD patients.12,13 The introduction of Medicare's TCM payment model in 2013 sought to close care gaps and reduce avoidable readmissions by incentivizing postdischarge care coordination. 14 Our findings support this model, demonstrating how targeted, patient-centered TCM interventions can reduce the heightened readmission rates in higher-risk populations like CKD. As a VBC organization, we prioritize patient-centered outcomes, reducing utilization, and fostering continuity of care—objectives that directly align with TCM.
This quality improvement case study reinforces the effectiveness of the TCM model, and healthcare agencies should consider adopting similar approaches that emphasize early intervention, patient education, and care coordination—especially for populations with advanced chronic conditions like CKD.
Limitations
The observed readmission rates in this study were lower than those reported by the USRDS. 2 This may be attributed to demographic factors, including geographic differences, health insurance plan coverage, data availability, and other associated health risks. We acknowledge that patients who agreed to TCM may be more engaged in their care, potentially influencing readmission rates. A key limitation of this study is the absence of qualitative data, which restricts our ability to capture patients’ perspectives on discharge planning and their lived experiences. Additionally, while our study had a smaller sample size, which may limit generalizability, we recognize the need for further research to confirm these findings and assess their broader applicability.
Conclusion
Our findings observed that patients with CKD stages 3 to 5 who participated in the TCM program had lower readmission rates compared to those who opted out of the program. These results highlight the importance of integrating comprehensive TCM programs with early intervention into post-hospitalization care to enhance patient outcomes and reduce hospital readmission rates.
Supplemental Material
sj-docx-1-jpx-10.1177_23743735251367076 - Supplemental material for Link From Hospital to Home: Ensuring Quality Transitions for CKD Patients
Supplemental material, sj-docx-1-jpx-10.1177_23743735251367076 for Link From Hospital to Home: Ensuring Quality Transitions for CKD Patients by Emily Simon, Melissa Feeney and Joan Mendenhall, Caroline Ruff, Tammy Cheung, Farhad Modarai, Muhammad Sohaib in Journal of Patient Experience
Footnotes
Acknowledgments
Not applicable.
Authors’ Contributions
E. Simon: conceptualization, formal analysis, methodology, project administration, supervision, visualization, writing–original draft, and writing–review and editing. M. Feeney: formal analysis, investigation, methodology, and writing–review and editing. J. Mendenhall: conceptualization and writing–review and editing. C. Ruff: conceptualization, formal analysis, investigation, methodology, and writing–review and editing. T. Cheung: conceptualization, investigation, and writing–review and editing. F. Modarai: conceptualization and writing–review and editing. M. Sohaib: conceptualization, methodology, project administration, supervision, writing–review & editing.
Declaration of Conflicting Interest
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors are employed by Strive Health.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Our organization does not require ethical approval for reporting individual quality improvement case studies.
Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
