1. Key facts about the uninsured population , https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ (2018, accessed 29 June 2021).
Google Scholar2. FAQ on transitional care management , https://www.aafp.org/practice-management/payment/coding/medicare-coordination-services/tcm/tcmfaq.html (2019, accessed 29 June 2021).
Google Scholar3. Feltner, C, Jones, CD, Cené, CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med 2014; 160: 774–784.
Google Scholar | Crossref | Medline | ISI4. Prvu Bettger, J, Alexander, KP, Dolor, RJ, et al. Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review. Ann Intern Med 2012; 157: 407–416.
Google Scholar | Crossref | Medline5. Bindman, AB, Cox, DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Intern Med 2018; 178: 1165–1171.
Google Scholar | Crossref | Medline6. Hansen, LO, Young, RS, Hinami, K, et al. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011; 155: 520–528.
Google Scholar | Crossref | Medline | ISI7. Jack, BW, Chetty, VK, Anthony, D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150: 178–187.
Google Scholar | Crossref | Medline | ISI8. Coleman, EA, Parry, C, Chalmers, S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006; 166: 1822–1828.
Google Scholar | Crossref | Medline9. Rodrigues, CR, Harrington, AR, Murdock, N, et al. Effect of pharmacy-supported transition-of-care interventions on 30-day readmissions: a systematic review and meta-analysis. Ann Pharmacother 2017; 51: 866–889.
Google Scholar | SAGE Journals | ISI10. Bailey, JE, Surbhi, S, Wan, JY, et al. Effect of intensive interdisciplinary transitional care for high-need, high-cost patients on quality, outcomes, and costs: a quasi-experimental study. J Gen Intern Med 2019; 34: 1815–1824.
Google Scholar | Crossref | Medline11. Agarwal, SD, Barnett, ML, Souza, J, et al. Adoption of Medicare's transitional care management and chronic care management codes in primary care. JAMA 2018; 320: 2596–2597.
Google Scholar | Crossref | Medline12. Husereau, D, Drummond, M, Petrou, S, et al. Consolidated health economic evaluation reporting standards (CHEERS) statement. Eur J Health Econ 2013; 14: 367–372.
Google Scholar | Crossref | Medline13. Drummond, MF, Sculpher, MJ, Claxton, K, et al. Methods for the economic evaluation of health care programmes. London: Oxford University Press, 2015.
Google Scholar14. Sanders, GD, Neumann, PJ, Basu, A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA 2016; 316: 1093–1103.
Google Scholar | Crossref | Medline15. Online Analytical Statistical Information System. https://oasis.state.ga.us/oasis/webquery/qryMorbidity.aspx (2020, accessed 1 March 2021).
Google Scholar16. Dummit, LA. Primary care physician supply, physician compensation, and Medicare fees: what is the connection? Issue brief (George Washington University, National Health Policy Forum: 2005). No. 827. 2008.
Google Scholar17. Germack, HD, Caron, A, Solomon, R, et al. Medical-surgical readmissions in patients with co-occurring serious mental illness: a systematic review and meta-analysis. Gen Hosp Psychiatry 2018; 55: 65–71.
Google Scholar | Crossref | Medline18. Gao, W, Keleti, D, Donia, TP, et al. Postdischarge engagement decreased hospital readmissions in Medicaid populations. Am J Manag Care 2018; 24: e200–e206.
Google Scholar | Medline19. Christensen, CM. The innovator's dilemma: when new technologies cause great firms to fail. Boston: Harvard Business Review Press, 2013.
Google Scholar