Retrospective Outcome Data for Transitional Care Management in the Hematologic Malignant Patient Population

Abstract

Introduction In 2016, providers within an Academic Medical Center's Blood and Marrow Transplant (BMT) program recognized preventable readmissions related to missed opportunities in the hospital discharge process. In an effort to address discharge deficiencies and reduce readmissions, Transitional Care Management (TCM) was developed and implemented by BMT Transplant Coordinators in 2017. Methods Hospital discharge reports are generated in the electronic medical record (EMR). Communication within the EMR is sent to the clinical teams the business day following discharge with instruction to initiate a telephone encounter. The clinical team completes a telephone encounter in the EMR and documents review of discharge summary, medications, follow-up appointments, pertinent clinical trial review (if applicable), and symptoms following discharge. Results Retrospective analysis of readmission rates for patients with hematologic malignancies for the period of January 1, 2016, through December 31, 2018, show a decline in readmission rates since implementation of TCM. (30 day- 2016 25.11% vs 2018 23.89%, 14 day 18.14% vs 2018 16.39%, 7 day 2016-13.5% vs 2018 9.6%) Retrospective analysis of TCM completion by BMT coordinators for the period of January 1, 2017 through August 31, 2019, reveal a drastic improvement. Compliance of TCM documentation and completion averaged 88% in 2017, and 85% in 2018. Since utilization of EMR generated telephone encounter notification, 98% completion of the TCM process has been documented. Conclusion TCM has improved quality of care for patients with hematologic malignancies. BMT 30-day, 14-day and 7-day readmission rates have improved since TCM. Utilization of the transplant center's upgraded EMR improved functionality and increased compliance of the TCM documentation process.