Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial

Abstract

Background Improving care transitions following emergency department (ED) visits may reduce post‐ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital‐to‐home transitions; however, its effectiveness at improving post‐ED outcomes is unknown. We tested the effectiveness of the CTI with community‐dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self‐management behaviors during the 30 days following discharge. Methods We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention‐to‐treat and per‐protocol (PP) analyses. Results Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30‐day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in‐person follow‐up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). Conclusions The CTI did not reduce 30‐day ED revisits but did significantly increase key care transition behaviors (outpatient follow‐up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Emergency department‐to‐community care transition barriers: A qualitative study of older adults

“…Recent work has highlighted an overall lack of high-quality data to guide recommendations about optimal ED-to-community care transition strategies for older adults. [14][15][16][17][18] With the extant literature demonstrating limited relevant qualitative data, 19,20 hypothesis-generating qualitative research may identify potential opportunities to improve care transitions, which could help generate novel ED-to-community care transition interventions to be tested and implemented among older adults.…”

Evaluation of a transitions clinic to bridge emergency department and primary care

“…Similar to transition interventions at Brigham Health and Harborview Medical Center, we found that early follow‐up combined with intensive social resource assistance significantly reduced subsequent ED visits versus a comparator group 15,16 . Other similar care transition interventions found no difference in the 30‐day ED revisits, but primary care engagement was improved 3,17 . Regarding subsequent hospitalization, we found that CTC participants were slightly more likely to be hospitalized within 30 days, though the results were not statistically significant.…”

“…This in‐person care and hand‐off to primary care clinicians may help stabilize patients' medical conditions and reduce disease exacerbations resulting in ED revisit. This concept is supported by studies that found interventions involving patient education but not on‐site medical treatment improved follow‐up behavior (outpatient follow‐up, red flag knowledge) but had no effect on subsequent ED utilization 3,19 . Second, CTC appointments are scheduled prior to ED discharge.…”

“…Our CTC differs from previous ED care transitions interventions in several key ways. First, in contrast to traditional ED care transition interventions such as phone‐based methods 18 or home visits, 3 the CTC provides on‐site medical care during the high‐risk post‐ED discharge period by clinicians. This in‐person care and hand‐off to primary care clinicians may help stabilize patients' medical conditions and reduce disease exacerbations resulting in ED revisit.…”

“…Successful completion of ED follow‐up has been linked to improved health outcomes and reduced ED utilization for nonurgent needs 1,2 . Important issues addressed during follow‐up include adherence to medications and treatment plans, understanding of discharge instructions, education of disease, changes in symptoms, and lack of social support 3 . Patients who do not complete ambulatory follow‐up are more likely to return to the ED and are at higher risk for adverse events, including double the risk of 30‐day postdischarge mortality 2,4 .…”