OBJECTIVES Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30‐day hospital readmissions nationwide. The Coordinated‐Transitional Care (C‐TraC) program is a telephone‐based, nurse‐driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non‐VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C‐TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. DESIGN We used the Replicating Effective Programs model to guide the implementation. The C‐TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. SETTING The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. PARTICIPANTS Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. MEASUREMENTS A total of 43 (15.8%) C‐TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90‐day hospital admission, and discharge diagnosis. RESULTS Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24‐.89). CONCLUSION The program was financially sustainable. The total cost of care in the 30‐day postdischarge period was $1842.52 less per C‐TraC patient than per controls, leading the medical center to sustain and expand the program.

Introduction: Type 2 diabetes mellitus and social disadvantage are related. In Australia, this association is most pronounced among Indigenous Australians (Aboriginal and Torres Strait Islander peoples). Indigenous Australians are among the most socially disadvantaged in the country, having the worst social determinants of health (SDoH). SDoH are typically addressed at a population level, and not on an individual or a clinical level.However, the SDoH-related needs of individuals also require attention. The adverse link between type 2 diabetes and SDoH suggests that simultaneous consideration at an individual, clinical level may be beneficial for type 2 diabetes care and selfmanagement. Identifying and addressing SDoH-related barriers to type 2 diabetes self-management may augment current care for Indigenous Australians. This study aimed to combine the perspectives of Indigenous Australians with type 2 diabetes and Indigenous health workers to explore the SDoH-related barriers and facilitators to self-managing type 2 diabetes, and how SDoH could be incorporated into the usual clinical care for Indigenous Australians with type 2 diabetes. Methods: Under the guidance of a cultural advisor and Indigenous health workers, seven Indigenous Australians with type 2 diabetes and seven Indigenous health workers from rural and remote north Queensland, Australia, participated in a series of semi-structured, in-depth face-to-face interviews and yarning circles. A clinical yarning approach to data collection was used, and both an inductive and a deductive data analysis were applied. Data were analysed, and themes were identified using NVivo v12.Results: Study participants described a holistic view of health that innately includes SDoH. Specific to type 2 diabetes care, participants identified that culturally responsive service delivery, suitable transport provision, an infinite flexible approach to accommodate for individuals' unique social circumstances, appropriate client education and appropriate cultural education for health professionals, support mechanisms and community support services were all essential components. These were not seen as separate entities, but as interrelated, and all were required in order to incorporate SDoH into care for Indigenous Australians with type 2 diabetes. Conclusion:SDoH are implicit to the Indigenous Australian holistic view of health. Consequently, an approach to type 2 diabetes care that complements this view by simultaneously considering SDoH and usual type 2 diabetes clinical management could lead to enhanced type 2 diabetes care and self-management for Indigenous Australians.