The US, Israel and other countries have increasingly recognized the importance of improving the coordination of care for patients as they transition from hospitals to the community. The Maccabi Transitional Care Program (MTCP) was established in 2015 by Maccabi Health Services, Israel’s second largest health plan. MTCP is a large-scale effort to improve hospital-community health services coordination. Under the auspices of MTCP, specially trained nurses communicate with Maccabi patients in order to assess their post-hospitalization care needs and to facilitate referrals to community-based providers.
The objectives of the study were to assess the impact of MTCP on promptness of post-discharge access to primary care physicians, the number of re-admissions over the ensuing 30 days, emergency department visits, the use of community-based health services, and health care expenditures.
The primary source of study data was Maccabi’s digitized system of patient records. In its primary approach, the research team used an intention to treat (ITT) analysis to compare the study’s outcome variables for patients discharged from hospital care prior to, and after MTCP’s implementation. The team then performed two secondary analyses using alternative study designs. The first of these used an “as treated” design and focused on patients discharged after MTCP’s implementation; it compared patients contacted by an MTCP nurse with those not contacted. The second analysis employed a hybrid approach – a pre-post comparison using an “as treated” design. We note that under certain conditions, the ITT analysis can be limiting because it does not adjust for differences between program design and implementation.
The ITT approach revealed that MTCP did not have significant effects on most of the outcome variables under study, programmatically or statistically. In contrast, the study’s secondary analysis using an “as treated” design (among patients discharged after MTCP implementation) revealed substantial differences in key process and outcome measures between patients contacted and those not contacted by MTCP nurses. The hybrid approach revealed a 7% increase in the proportion of patients who visited a primary care physician within a week of hospital discharge, but no change in the hospital re-admission rate.
Conclusions and policy recommendations
The study raises questions about the effectiveness of the MTCP program during the study period. The findings suggest that in order to improve MTCP’s effectiveness, structures and processes need to be modified. Modifications might include greater focus on patients with multiple chronic illnesses, those over age 75, and other populations that are less likely to visit primary care physicians without a call from an MTCP nurse, as well as improved procedures to increase the incidence of MTCP nurse contact with patients soon after hospital discharge.
Citing suggestion: Rosen, B., Kagya, S., Abou-Hussein, C., Zwanziger, J., Porath, A. & Landon, B. E. (2022). Estimating the Impact of Maccabi’s Transitional Care Program. RR-900-22. Myers-JDC-Brookdale Institute. (Hebrew)