Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

  • James E. BaileyEmail author
  • Satya Surbhi
  • Jim Y. Wan
  • Kiraat D. Munshi
  • Teresa M. Waters
  • Bonnie L. Binkley
  • Michael O. Ugwueke
  • Ilana Graetz
Original Research



Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.


To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.


Quasi-experimental study.


Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.


The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

Main Measures

Primary difference‐in‐differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30‐day readmissions, and hospital days), and medical expenditures.

Key Results

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (− 0.40; 95% confidence interval (CI), − 0.73 to − 0.06), 31% fewer 30-day readmissions (− 0.34; 95% CI, − 0.61 to − 0.07), and reduced medical expenditures ($− 8690; 95% CI, $− 14,441 to $− 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, − 39.1% to 72.9%).


Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.


care transitions chronic disease health care delivery underserved populations quality improvement super-utilizer multiple chronic conditions Medicaid Medicare 


Author Contributions

The authors gratefully acknowledge Patti Smith, MPH, for her editorial assistance; Karen Hopper, MD, Michelle Scroggins, FNP, Paula Bell, PharmD, Angel Jones, PharmD, Leigh Anne Keough, PharmD, Caprice Brown, RN, Bonnye Griffin, MSW, Cassandra Norwood, MSW, Patricia Wright, LPN, Brittney Willoughby, LPN, Justin Wright, CPT, Amanda Clayborne-Clark, CPT, Jill Connors, PhD, Sarah Henning, MHSA, and Mansoor Shahid, MHA for their dedicated service to vulnerable patients in need; and most importantly, to the people served by the SafeMed program who helped us understand the care they need most.


The project described was supported by Grant Number ICIMS 331067-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. In addition, this work was partially supported by the University of Tennessee Health Science Center and the Robert S. Pearce Endowed Chair in Internal Medicine.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5082_MOESM1_ESM.docx (63 kb)
ESM 1 (DOCX 62.9 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • James E. Bailey
    • 1
    • 2
    • 3
    Email author
  • Satya Surbhi
    • 1
    • 2
  • Jim Y. Wan
    • 1
    • 3
  • Kiraat D. Munshi
    • 4
  • Teresa M. Waters
    • 1
    • 3
    • 5
  • Bonnie L. Binkley
    • 1
    • 2
  • Michael O. Ugwueke
    • 6
  • Ilana Graetz
    • 1
    • 3
    • 7
  1. 1.Center for Health System ImprovementUniversity of Tennessee Health Science CenterMemphisUSA
  2. 2.Department of MedicineUniversity of Tennessee Health Science CenterMemphisUSA
  3. 3.Department of Preventive MedicineUniversity of Tennessee Health Science CenterMemphisUSA
  4. 4.Express Scripts Holding CompanyMemphisUSA
  5. 5.Department of Health Management and PolicyUniversity of Kentucky College of Public HealthLexingtonUSA
  6. 6.Methodist Le Bonheur HealthcareMemphisUSA
  7. 7.Department of Health Policy and ManagementEmory University Rollins School of Public HealthAtlantaUSA

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