National Daily Hospital Executive Briefing Thursday December 11th, 2025

 

National Daily Hospital News – Executive Briefing

Thursday, December 11, 2025
Focus Topics:
1. Transitional Care Management (TCM), Discharge Coordination, and Readmissions
2. Hospital Closures and Rural Access

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1. Transitional Care Management, Discharge Coordination, and Readmissions

A. News

1. TCM visits linked to lower 30-day readmissions.
   A large PLoS ONE study of more than 67,000 patients found that transitional care management (TCM) follow-up visits within 14 days of discharge were associated with a 26% relative reduction in 30-day readmissions compared with non-TCM visits, and patients seen by providers who frequently bill TCM codes had even lower readmission risk.
   https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316892
2. Nurse-led transitional care reduces readmissions and ED visits.
   A 2025 systematic review and meta-analysis reported that nurse-led transitional care programs for adults discharged from hospital significantly reduced all-cause readmissions and emergency department visits while improving quality of life, supporting the value of structured nursing follow-up.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC11974112/
3. Early clinic follow-up helps high-risk medical patients.
   A CDC Preventing Chronic Disease study found that scheduling and completing outpatient follow-up visits after discharge for heart failure and stroke patients was associated with lower 30-day all-cause readmissions, reinforcing “visit booked before discharge” as a core readmission countermeasure.
   https://www.cdc.gov/pcd/issues/2024/24_0138.htm
4. Electronic health record (EHR) prompts can cut readmissions.
   A 2025 JAMA Network Open analysis of EHR-based discharge and follow-up interventions showed a 17% reduction in 30-day readmissions and a 28% reduction in 90-day readmissions, highlighting how embedded clinical decision support can hard-wire safer transitions.
   https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2836552

B. Recommendations

1. Standardize TCM pathways for all high-risk discharges.
   Use the CMS Transitional Care Management Services guidance (CPT 99495/99496) to build a standard pathway that includes risk stratification, patient/caregiver outreach within 2 business days, and a follow-up visit within 7–14 days for all high-risk medical patients.
   https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf
2. Hard-wire “7-day or sooner” clinic follow-up for target conditions.
   For heart failure, COPD, stroke, and other HRRP-sensitive diagnoses, configure discharge workflows and scheduling templates so that no patient leaves the hospital without a confirmed clinic or virtual follow-up within 7 days, prioritizing heart failure and stroke where evidence of readmission benefit is strongest.
   https://www.cdc.gov/pcd/issues/2024/24_0138.htm
   https://pmc.ncbi.nlm.nih.gov/articles/PMC12161123/
3. Scale nurse-led transition teams with clear handoff standards.
   Build multidisciplinary, nurse-led transition teams that use standardized discharge summaries, medication reconciliation, and teach-back, as meta-analysis shows these programs reduce readmissions and ED visits while improving patient-reported outcomes.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC11974112/
   https://pmc.ncbi.nlm.nih.gov/articles/PMC12161123/
4. Leverage telehealth and remote monitoring for high-risk patients.
   Evidence from telemonitoring and virtual transition-of-care clinics shows that home monitoring plus virtual visits can lower readmissions, ED visits, and total utilization for chronic disease populations; consider remote programs for rural or transportation-limited patients.
   https://formative.jmir.org/2024/1/e53455
   https://medinform.jmir.org/2025/1/e73495

C. Case Studies

1. New Case Study – Virtual Transition of Care Clinic.
   A health system implemented a virtual transitions of care (VToC) clinic staffed by pharmacists and advanced practice providers; the program was associated with significantly lower 30-day readmissions among high-risk medical patients compared with usual care, demonstrating that virtual TCM infrastructure can be both scalable and effective.
   https://medinform.jmir.org/2025/1/e73495
2. New Case Study – Continuing Care Clinics reduce readmissions in Michigan.
   MyMichigan Health’s Continuing Care Clinics, serving a 26-county region, provide free post-discharge follow-up, social needs navigation, and multidisciplinary support, and have been recognized with a statewide community benefit award for reducing readmissions and improving access for patients without regular primary care.
   https://www.ourmidland.com/news/article/mymichigan-health-honored-reducing-readmissions-20416620.php
3. New Case Study – Loma Linda University Health TCM implementation.
   Loma Linda’s population-health team highlights how structured transitional care management, with team-based follow-up and proactive outreach, reduced 30-day readmissions and improved medication safety in high-risk populations, reinforcing TCM as a patient safety strategy.
   https://ihpl.llu.edu/blog/transitional-care-management-ensuring-patient-safety

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2. Hospital Closures and Rural Access

A. News

1. Nearly half of rural hospitals operate in the red, with hundreds at risk.
   The 2025 Chartis “Rural Health – State of the State” report finds that 46% of rural hospitals have negative operating margins and 432 facilities are now vulnerable to closure; 18 hospitals closed or converted away from inpatient care in the last year alone.
   https://www.chartis.com/insights/2025-rural-health-state-state
2. Medicaid cuts would accelerate closures and service reductions.
   An American Hospital Association fact sheet warns that nearly half (48%) of rural hospitals already operate at a loss, 92 rural hospitals have closed or eliminated inpatient care in the past decade, and proposed Medicaid funding cuts would further threaten access to obstetrics, chemotherapy, and behavioral health.
   https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-risk-cuts-medicaid-would-further-threaten-access
   https://www.ruralhealth.us/getmedia/f79547dc-19b6-4f39-ac95-4f24ba0e0a84/OBBB-Impacts-On-Rural-Communities_06-20-25-final_v3-%28002%29.pdf
3. Rural closures and conversions reshape the care map.
   KFF reports that rural hospital closures have outpaced openings from 2017–2024, and that many surviving facilities have cut service lines such as obstetrics and behavioral health, effectively shifting risk and travel burden to patients and regional hubs.
   https://www.kff.org/health-costs/10-things-to-know-about-rural-hospitals/
4. Federal assistance does not fully offset financial distress.
   A 2025 USDA Economic Research Service report concludes that severe financial stress remains the primary driver of rural hospital closures despite multiple federal support programs, indicating that existing assistance is not sufficient to stabilize the most vulnerable facilities.
   https://www.ers.usda.gov/sites/default/files/_laserfiche/publications/110766/ERR-344.pdf
5. Policy spotlight – Rural Emergency Hospital (REH) conversions.
   MedPAC’s 2024 mandated report on Rural Emergency Hospitals notes that eight rural hospitals closed in 2023 rather than converting to REH status, citing timing, capital constraints, and commercial payer dynamics, suggesting that REH alone will not prevent all closures.
   https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch15_MedPAC_Report_To_Congress_SEC.pdf

B. Recommendations

1. Add travel-time metrics to your rural access dashboard.
   A 2025 JAMA Network Open study shows that patients with emergency surgical conditions who travel ≥60 minutes to a hospital have higher odds of complex disease, interfacility transfer, admission, longer stays, and higher charges than those within 15 minutes, suggesting travel time is a more actionable access metric than “rural” labels alone.
   https://pubmed.ncbi.nlm.nih.gov/39836423/
2. Map and monitor “service line deserts,” not just hospital closures.
   KFF and AHA document that many rural hospitals maintain an emergency department but eliminate obstetrics, behavioral health, or inpatient beds, effectively creating service-line deserts even where a facility still exists; boards should track service availability across regions, not just facility counts.
   https://www.kff.org/health-costs/10-things-to-know-about-rural-hospitals/
   https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-risk-cuts-medicaid-would-further-threaten-access
3. Use state and federal programs aggressively to stabilize distressed facilities.
   The USDA ERS report and a 2025 National Conference of State Legislatures brief show that low-volume rural hospitals can tap Community Facilities loans, state technical assistance, and payment reforms to improve cash flow, but uptake is uneven; leadership teams should proactively pursue these options before margins turn irreversibly negative.
   https://www.ers.usda.gov/sites/default/files/_laserfiche/publications/110766/ERR-344.pdf
   https://www.ncsl.org/health/supporting-rural-health-facilities
4. Integrate outpatient, telehealth, and EMS partners into rural access strategy.
   Rural Health Information Hub highlights that rural residents use emergency departments more often than urban residents, including for non-urgent care, emphasizing the need to integrate primary care, urgent care, EMS, and telehealth into a single access plan for each catchment area.
   https://www.ruralhealthinfo.org/topics/healthcare-access
   https://edhub.ama-assn.org/ama-journal-of-ethics/module/2835824
5. Scenario-plan around Medicaid and coverage cuts.
   Recent news analyses and fact checks indicate that large proposed Medicaid cuts could place hundreds of rural hospitals at risk of closure over the next decade, with ripple effects on local employment and access to maternity and emergency care; governance teams should model financial scenarios with and without these cuts.
   https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-risk-cuts-medicaid-would-further-threaten-access
   https://apnews.com/article/a570794b3431c342fd9ba547e0b953f2
   https://www.investopedia.com/medicaid-cuts-hurt-economy-11779578

C. Case Studies

1. New Case Study – “When the hospital leaves town.”
   A recent FierceHealthcare feature describes multiple rural facilities that have converted to Rural Emergency Hospitals, closing inpatient beds and obstetrics while keeping 24/7 ED coverage, illustrating a “survival by subtraction” model that preserves some access but requires patients to travel farther for admission and surgery.
   https://www.fiercehealthcare.com/hospitals/when-hospital-leaves-town
2. New Case Study – Regional analysis of travel time and emergency surgery.
   The JAMA Network Open cohort study of more than 190,000 emergency general surgery patients in Florida and California found that those traveling ≥60 minutes were substantially more likely to have complex disease, require admission and transfer, and incur higher costs, quantifying the real-world impact of distance and regionalization.
   https://pubmed.ncbi.nlm.nih.gov/39836423/
3. New Case Study – State policy responses to protect rural facilities.
   The NCSL review of state initiatives outlines how states such as Colorado, Pennsylvania, and Texas are using global budgets, rural transformation models, and targeted grants to maintain rural access, offering a menu of approaches boards can advocate for in their own states.
   https://www.ncsl.org/health/supporting-rural-health-facilities

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Quality Metrics to Share with Your Team

1. TCM hazard ratio for 30-day readmission.
   Patients who had a TCM visit within two weeks of discharge had a 26% lower risk of 30-day readmission (HR 0.74; 95% CI 0.63–0.88) than those with non-TCM visits.
   https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316892
2. Impact of nurse-led transitional care programs.
   A 2025 meta-analysis found that nurse-led transitional care interventions reduced readmissions and ED visits and improved quality of life for discharged adults.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC11974112/
3. Early post-discharge follow-up for heart failure and stroke.
   Timely outpatient follow-up visits after discharge were associated with lower 30-day all-cause readmissions for patients with heart failure and stroke compared with those without follow-up.
   https://www.cdc.gov/pcd/issues/2024/24_0138.htm
4. EHR-based interventions and readmission reduction.
   Health systems implementing EHR-driven discharge and follow-up interventions achieved 17% lower 30-day and 28% lower 90-day all-cause readmissions.
   https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2836552
5. Rural financial distress at scale.
   Chartis estimates that 46% of rural hospitals operate with negative margins and that 432 facilities are vulnerable to closure.
   https://www.chartis.com/insights/2025-rural-health-state-state
6. Closures already reshaping the map.
   AHA reports that 92 rural hospitals have closed or ceased inpatient services over the past 10 years, with nearly half of remaining rural hospitals operating at a loss.
   https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-risk-cuts-medicaid-would-further-threaten-access
7. Travel time as an access and severity metric.
   In a 2025 study of 190,311 emergency surgical patients, those traveling ≥60 minutes to care had higher odds of admission and interfacility transfer, longer length of stay, and higher charges than those within 15 minutes.
   https://pubmed.ncbi.nlm.nih.gov/39836423/

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The Weather Forecast for Today: 12-Month Scenarios

1. Scenario 1 – Coordinated Transitional Care Stabilizes Readmissions (Best-Case).
   Hospitals scale TCM, nurse-led transition teams, and virtual clinics, driving down 30-day readmissions by 15–25% in target populations and freeing capacity in EDs and inpatient units; rural hospitals that combine stronger care coordination with payer partnerships modestly improve margins and avoid closures despite ongoing financial pressure.
2. Scenario 2 – Uneven Adoption and Persistent Hot Spots (Middle-Case).
   A subset of systems invest in robust transition programs and realize measurable readmission gains, but others lag due to staffing shortages and capital constraints; rural closures and service-line reductions continue at today’s pace, increasing travel times and ED overcrowding in certain regions even as some systems improve transitions.
3. Scenario 3 – Coverage Cuts and Accelerated Rural Closures (Worst-Case).
   If proposed Medicaid cuts proceed and no offsetting reforms are enacted, hundreds of rural hospitals face deeper negative margins, accelerating closures and conversions to lower-service models; readmissions and ED boarding rise in regional hubs as travel times increase and rural communities lose local access, especially for obstetrics, behavioral health, and post-acute coordination.
4. Scenario 4 – Integrated Regional Networks Emergent (Transformational).
   Some states and health systems use this period to build integrated regional networks—combining rural ED “front doors,” hub hospitals, FQHCs, and telehealth—and adopt travel-time metrics as a core access KPI, reducing preventable delays even as the footprint of inpatient beds shrinks.

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Leadership Call to Action

1. Stand up or strengthen a high-risk TCM program within 90 days.
   Identify top readmission diagnoses, designate accountable physician and nursing leads, and implement a TCM pathway (including 2-day outreach and 7-day follow-up) with dashboards that show readmissions by service line and TCM completion rates.
2. Make “no discharge without a booked follow-up” your operating rule.
   Hard-wire scheduling so every high-risk discharge leaves with a confirmed in-person or virtual follow-up appointment, and monitor exceptions daily through your bed management or throughput huddle.
3. Adopt travel-time and service-line maps as board-level metrics.
   Create maps showing travel time to emergency and inpatient care and overlay planned or recent closures, service-line reductions, and referral patterns; report regularly to the board and local partners.
4. Launch a Rural Access and Stability Workgroup.
   For systems with rural catchment, form a cross-functional group (finance, strategy, clinical, EMS, community partners) to review risk metrics, state and federal support options, and potential REH or partnership models before a crisis forces closure.
5. Integrate TCM success with rural access strategy.
   Tie readmission reduction targets to rural access goals by prioritizing TCM and telehealth for patients who must travel the longest distances, using remote monitoring and local clinics to extend the reach of your hospitalist and specialty teams.

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