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Objectives. To evaluate impacts of a telephonic transitional care program on service use and spending for Medicare fee-for-service beneficiaries at a rural hospital.

Study Design. Observational cohort study.

Methods. Patients discharged from Atlantic General Hospital (AGH) with an AGH primary care provider were assigned a nurse care coordinator for 30 days. The nurse reviewed the patient’s conditions, assessed needs for transition support, conducted weekly telephone calls (beginning 24-72 hours after discharge) to monitor adherence to treatment plans, and scheduled follow-up appointments. Using claims data, we evaluated impacts on service use and spending using a difference-in-differences design with a matched comparison group.

Results. The intervention reduced Medicare spending in the 6-month period after discharge by 30.8%, or $1333 per beneficiary per month (90% CI, –$2078 to –$589), which was partly driven by a 39.4% reduction in spending for inpatient claims (difference, –$729; 90% CI, –$1234 to –$225). There were no statistically significant changes in the 14-day ambulatory care follow-up rate, 30-day unplanned readmission rate, number of inpatient admissions, or number of emergency department visits, although this may be due to modest statistical power to detect effects.

Conclusions. The estimated $5.4 million in savings from this intervention more than offset the costs of the $1.1 million funding for the award. Although other studies have found that care transitions programs can improve outcomes, this study was unique in the size of the impacts relative to the low-touch intervention and the location in a small rural healthcare system.