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.

Aims and objectives Our objective was to rapidly adapt and scale a registered nurse‐driven Coordinated Transitional Care (C‐TraC) programme to provide intensive home monitoring and optimise care for outpatient Veterans with COVID‐19 in a large urban Unites States healthcare system. Background Our diffuse primary care network had no existing model of care by which to provide coordinated result tracking and monitoring of outpatients with COVID‐19. Design Quality improvement implementation project. Methods We used the Replicating Effective Programs model to guide implementation, iterative Plan‐Do‐Study‐Act cycles and SQUIRE reporting guidelines. Two transitional care registered nurses, and a geriatrician medical director developed a protocol that included detailed initial assessment, overnight delivery of monitoring equipment and phone‐based follow‐up tailored to risk level and symptom severity. We tripled programme capacity in time for the surge of cases by training Primary Care registered nurses. Results Between 23 March and 15 May 2020, 120 Veterans with COVID‐19 were enrolled for outpatient monitoring; over one‐third were aged 65 years or older, and 70% had medical conditions associated with poor COVID‐19 outcomes. All Veterans received an initial call within a few hours of the laboratory reporting positive results. The mean length of follow‐up was 8.1 days, with an average of 4.2 nurse and 1.3 physician or advanced practice clinician contacts per patient. The majority (85%) were managed entirely in the outpatient setting. After the surge, the model was disseminated to individual primary care teams through educational sessions. Conclusion A model based on experienced registered nurses can provide comprehensive, effective and sustainable outpatient monitoring to high‐risk populations with COVID‐19.