Implementation of a Care Transitions Model for Low‐Income Older Adults: A High‐Risk, Vulnerable Population

Abstract

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.

Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population

“…In a previous study of 121 vulnerable patients utilizing care transitions, there was no difference in rehospitalizations at 180-days. 20 In a trial of 363 hospital patients at risk for rehospitalization, an APC at the hospital and doing home visits reduced 24 week rehospitalization from 37.1% in the intervention group vs 20.3% in controls P o0.001. 3 Although the current focus of post-acute care has involved the use of the 30 day rehospitalization rate as a hospital quality measure, a cycle of 180 days provides a more useful construct as a measure of population health management, especially to achieve the triple aim.…”

Hospital to Community Transitions for Adults: Discharge Planners and Community Service Providers’ Perspectives

“…Research suggests that better decision making during hospital discharge planning can lead to positive outcomes such as lower rehospitalization rates (Craig & Muskat, 2013;Bowles, Foust, & Naylor, 2003;Kane et al, 2000), reduced length of stay, and increased patient satisfaction during and post hospital stay (Driscoll, 2000;Holland et al 2003;Laing & Behrend, 1998;Naylor 2000Naylor , 2002Payne et al 2002;Russell, 2000). Failure to plan for effective transition from the hospital to the community leads to higher rates of rehospitalization, patient difficulties conducting activities of daily living post discharge, and an increase in illness and morbidity (Ohuabunwa, Jordan, Shah, Fost, & Flacker, 2013).…”

A conceptual framework for evaluating the conceptualization, implementation and performance of transitional care programmes

“…The initial step in developing the model was to be explicit about the intended impact of the TC approach. This was consistently uniform in the literature: reduce avoidable hospital admission and ED visits; reduce cost to the national/regional health system; and improve/maintain quality of life and functions [8,10,[14][15][16][17][18][19][20][21][22][23][24][25][26]. Adopting the key components of the CTI [12] and the TCM [11] and our qualitative results, four major categories of influences were identified: (1) the context in which the TC programmes are introduced; (2) the readiness of the hospitals/regional health systems to adopt and implement the approach; (3) the specific implementation activities the programme managers/implementers pursued; and (4) the intermediate outcomes of those activities (Fig.…”