They all involved some version of risk stratification and a combination of telephonic and in-person nurse-based care management.
And they all worked.
Which is why the Annals of Internal Medicine could have saved itself a lot of time and effort by simply asking the PHB for a summary. Instead, it did the next best thing and published this meta-analysis by Feltner et al. The authors pooled the data from 47 randomized clinical trials and found that both in-person and telephonic nurse-led disease care management reduced readmissions to a statistically significant degree.
1. This is another example of old news not making reaching the elite ruling classes of Academikstan until well after the fact.
2. For my colleagues in the medical home movement, take note: achieving financially relevant outcomes will depend on focusing care management where it will have greatest impact. Instead of managing all patients with heart failure (for example), start by managing the patients at risk of (re) hospitalization. That's where the return-on-investment gold can be mined.
Image from Wikipedia