The Care Transitions Intervention

Coleman, Eric A.; Parry, Carla; Chalmers, Sandra; Min, Sung‐Joon

doi:10.1001/archinte.166.17.1822

Cited by 1,618 publications

(794 citation statements)

References 31 publications

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“…39,40 The reduction in readmissions among those over 60 is similar to other effective post-discharge programs. 11,15 However, ours is the first study to successfully employ CHWs in reducing readmissions in an older population. While not medically licensed, the PNs were trained to recognize when medical assistance was necessary and could readily engage primary care nursing; they also provided logistical assistance and motivational support.…”

Section: Discussionmentioning

confidence: 91%

“…2 They are more likely to be non-English speakers, 3 have lower health literacy, which can impair selfmanagement; [4][5][6] higher rates of mental health and substance abuse disorders; 7 greater exposure to social stressors; 6 and are more likely to experience hospital readmission. [8][9][10] Several care transitions programs [11][12][13][14][15][16] have demonstrated success in decreasing hospital readmissions. These programs have primarily targeted elderly Medicare populations or patients with high risk diagnoses, such as heart failure.…”

Section: Introductionmentioning

confidence: 99%

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A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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BACKGROUND: Evidence-based interventions to reduce hospital readmissions may not generalize to resourceconstrained safety-net hospitals. OBJECTIVE: To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN: Randomized controlled trial. PARTICIPANTS: General medicine inpatients having at least one of the following readmission risk factors: (1) age≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS: PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES: The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS: Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS: A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.KEY WORDS: care transitions; continuity of care; health care delivery; patient safety; underserved populations. J Gen Intern Med 30(7):907-15

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Section: Discussionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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“…Measures focusing on supportive discharge interventions have been shown to enhance patient capacity for self‐care and have helped to avoid readmissions 19. Comprehensive programs that focus on both inpatient and outpatient interventions and utilize tools that facilitate cross‐site communication can lead to a decrease in early readmissions 20, 21. Programs focusing on reducing 30‐day readmissions should take into account that over one third of all readmissions occur for noncardiac reasons, with two thirds of post‐CABG patients being readmitted for medical conditions within 30 days.…”

Section: Discussionmentioning

confidence: 99%

Thirty‐Day Readmission Rates, Timing, Causes, and Costs after ST‐Segment–Elevation Myocardial Infarction in the United States: A National Readmission Database Analysis 2010–2014

Kim

Yeo

Cheung

et al. 2018

JAHA

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BackgroundReadmission after ST‐segment–elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. Efforts to prevent readmissions should be based on understanding the timing and causes of these readmissions. This study aimed to investigate contemporary causes, timing, and cost of 30‐day readmissions after STEMI.Methods and ResultsAll STEMI hospitalizations were selected in the Nationwide Readmissions Database (NRD) from 2010 to 2014. The 30‐day readmission rate as well as the primary cause and cost of readmission were examined. Multivariate regression analysis was performed to identify the predictors of 30‐day readmission and increased cumulative cost. From 2010 to 2014, the 30‐day readmission rate after STEMI was 12.3%. Within 7 days of discharge, 43.9% were readmitted, and 67.3% were readmitted within 14 days. The annual rate of 30‐day readmission decreased by 19% from 2010 to 2014 (P<0.001). Female sex, AIDS, anemia, chronic kidney disease, collagen vascular disease, diabetes mellitus, hypertension, pulmonary hypertension, congestive heart failure, atrial fibrillation, and increased length of stay were independent predictors of 30‐day readmission. A large proportion of patients (41.6%) were readmitted for noncardiac reasons. After multivariate adjustment, 30‐day readmission was associated with a 47.9% increase in cumulative cost (P<0.001).ConclusionsTwo thirds of patients were readmitted within the first 14 days after STEMI, and a large proportion of patients were readmitted for noncardiac reasons. Thirty‐day readmission was associated with an ≈50% increase in cumulative hospitalization costs. These findings highlight the importance of closer surveillance of both cardiac and general medical conditions in the first several weeks after STEMI discharge.

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“…For example, Project RED (Re-Engineered Discharge) decreased 30-day emergency department visits and readmissions by about 30% among patients randomized to receive an intervention involving 12 discrete, mutually reinforcing components [6] . The Care Transitions Intervention (CTI) also decreased 30-day hospital readmission by about 30% among patients who were randomized to receive health coaching for 30 days following hospital discharge [4] and in another quality improvement intervention [18] . The CTI focuses on empowering high-risk patients to better manage their illnesses through a home visit and telephone calls by trained transitions coaches [4] .…”

Section: Discussionmentioning

confidence: 99%

“…healthcare costs [4][5][6] . During care transitions, patients' clinicians, including hospital-based clinicians and communitybased primary care providers (PCPs), are responsible for sharing clinical information across settings and communicating directly, if necessary, to address time-sensitive questions and to transfer accountability for patients' care [1,2,7] .…”

mentioning

confidence: 99%

Is audit and feedback associated with increased hospital adherence to standards for communication during patient care transitions?

Baier

Limpahan

Butterfield

et al. 2014

JHA

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Guidelines to enhance communication during patient care transitions between healthcare settings have the potential to improve patient outcomes and satisfaction, as well as to decrease overall costs. In 2009, Healthcentric Advisors, the Medicare Quality Improvement Organization (QIO) for New England, collaborated with Rhode Island providers and stakeholders to develop communitywide standards for hospitals, the Safe Transitions Best Practice Measures for Hospitals and then implemented a hospital quality improvement intervention. As part of this intervention, 10 of the state's 11 acute-care hospitals collected quarterly data and Healthcentric Advisors provided audit and feedback reports showing each facility's progress and the state's average performance. Using hospital-reported data on four best practice measures and Medicare claims data for Q2 2011-Q1 2013, we performed descriptive analyses of (1) inpatient-to-outpatient communication for all patients at the 10 participating hospitals, as measured by four best practice measures, and (2) state-wide all-cause, 30-day readmission rates per 1,000 fee-for-service (FFS) beneficiaries. Aggregate performance for the four best practice process measures increased by 5.5% to 217.6% for all patients who met eligibility criteria (p ≤ .001 for each measure) and the readmission rate decreased by 18.4% from 14.12 to 11.52 per 1,000 eligible FFS Medicare beneficiaries (p ≤ .001). These findings suggest that communitywide standards, such as the Safe Transitions Best Practice Measures for Hospitals, and audit and feedback interventions can successfully improve hospitals' communication during patient care transitions between healthcare settings.

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The Care Transitions Intervention

Abstract: 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.

Cited by 1,618 publications

References 31 publications

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

Thirty‐Day Readmission Rates, Timing, Causes, and Costs after ST‐Segment–Elevation Myocardial Infarction in the United States: A National Readmission Database Analysis 2010–2014

Is audit and feedback associated with increased hospital adherence to standards for communication during patient care transitions?

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