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.
The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations--The Care Transitions Intervention--could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.
Following endorsement by National Quality Forum, findings support use of the CTM in national public reporting efforts. The 3-item CTM closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.
The objectives of this study were: (1) to demonstrate the ability of the Care Transitions Measure (CTM) to identify care deficiencies; (2) to devise and implement a quality improvement approach designed to remedy these deficiencies; (3) to assess the impact of the quality improvement approach on CTM scores; and (4) to test whether the CTM-3 predicts return to the emergency department. The CTM was found to be a sensitive tool able to capture changes in performance. The 3-item CTM was found to significantly predict post-hospital return to the emergency department within the first 30 days (p = 0.004).
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