Transitional Care Management Quality Improvement Methods That Reduced Readmissions in a Rural, Primary Care System

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).

From Dartmouth Health, Lebanon, NH (TEB, DSM, BJO, AE, JR, SH); Department of Community and Family Medicine, Geisel School of Medicine, Hanover, NH (TEB, BJO); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (TEB, BJO); Department of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program (BJO); Department of Medicine, Geisel School of Medicine, Hanover, NH (SH); Mongan Institute, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (SJB).