Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.

OBJECTIVES:To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates. DESIGN: Quasi-experimental design whereby subjects receiving the intervention (n 5 158) were compared with control subjects derived from administrative data (n 5 1,235). SETTING: A large integrated delivery system in Colorado. PARTICIPANTS: Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions. INTERVENTION: Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach. MEASUREMENTS: Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects' care experience was assessed using the care transitions measure. RESULTS: The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI) 5 0.28-0.96) at 30 days, 0.43 (95% CI 5 0.25-0.72) at 90 days, and 0.57 (95% CI 5 0.36-0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen. CONCLUSION: Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.

Background Cancer survivors represent a growing population, heterogeneous in their need for medical care, psychosocial support, and practical assistance. To inform survivorship research and practice, this manuscript will describe the prevalent population of cancer survivors in terms of overall numbers and prevalence by cancer site and time since diagnosis. Methods Incidence and survival data from 1975–2007 were obtained from the Surveillance, Epidemiology, and End Results Program and population projections from the United States (US) Census Bureau. Cancer prevalence for 2012 and beyond was estimated using the Prevalence Incidence Approach Model, assuming constant future incidence and survival trends but dynamic projections of the US population. Results As of January 1, 2012, approximately 13.7 million cancer survivors were living in the US with prevalence projected to approach 18 million by 2022. Sixty-four percent of this population have survived ≥ 5 years; 40% have survived ≥ 10 years; and 15% have survived ≥ 20 years after diagnosis. Over the next decade, the number of people who have lived ≥ 5 years after their cancer diagnosis is projected to increase approximately 37% to 11.9 million. Conclusions A coordinated agenda for research and practice is needed to address cancer survivors’ long-term medical, psychosocial, and practical needs across the survivorship trajectory. Impact Prevalence estimates for cancer survivors across the survivorship trajectory will inform the national research agenda as well as future projections about the health service needs of this population.