Low-income older adults are particularly vulnerable during care transitions. The present study evaluated the effectiveness of a transitional care model in this population. A quasi-experimental design was used to compare outcomes in the intervention group with historical controls at 30, 90, 180, and 365 days after discharge, along with a pre-postintervention evaluation of the intervention group. Eligible individuals were age 60 and older hospitalized between June 2008 and January 2009. Main outcome measures were readmissions, emergency department (ED) visits, and primary care services use. Of 121 participants, 55% were female and 90% African American, with a mean age of 69. Readmission rates were generally but not significantly lower in the intervention group than in controls (Day 30, 9.6% vs 17.3%; Day 90, 28.9% vs 25.0%; Day 180, 32.7% vs 36.5%; Day 365, 44.2% vs 53.9%; P > .05), as were ED visit rates (Day 30, 17.3% vs 15.4%; Day 90, 32.7% vs 34.6%; Day 180, 38.5% vs 40.4%; Day 365, 50.0% vs 55.8%; P > .05). Primary care service utilization rates were significantly higher in the intervention group than in controls at Day 30 (40.4% vs 19.2%, P < .001), 90 (74.9% vs 32.7%, P < .001), and 180 (65.4% vs 32.7%, P < .001). The lack of statistically significant reduction in readmissions and ED visits with the intervention, may suggest the need for additional assistance during care transitions for this vulnerable population.

Background/Objectives Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost‐prohibitive resource needs. Cost‐effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs. Design A cohort study with a pre–post intervention evaluation of the intervention group. Setting A 953‐bed academic urban safety‐net hospital. Participants Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission. Intervention Promotion of self‐management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self‐management education. Measurements Outcome measures were readmissions, ER visits, and PCP establishment. Results Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z = 9.6, p < 0.001), also observed at 30‐day (Z = 5.5, p < 0.001), 3‐month (Z = 4.3, p < 0.001), 6‐month (Z = 4.0, p = 0.001), and 1‐year (Z = 5.4, p < 0.001) post‐intervention. There was a significant reduction in the overall number of ER visits (Z = 5.5, p < 0.001), also seen at 3‐month (Z = 3.3, p < 0.001), 6‐month (Z = 3.0, p < 0.001), and 1‐year (Z = 4.0, p < 0.001) intervals. Care with a PCP was established in 86.6% of participants. Utilization costs were significantly lower post‐intervention ($11,530,376.39 vs $4,017,493.17, p < 0.001). Conclusion Use of CHWs during transitions of care may be a cost‐effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems.

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