Effectiveness of a National Transitional Care Program in Reducing Acute Care Use

Abstract

This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals' conditions, effectively articulate their preferences, and enable self-management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score-based weighting. Participant and caregiver surveys on quality of life and self-rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score-adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5-0.6) and 0.81 (95% CI = 0.72-0.90) 30 days after discharge and 0.6 (95% CI = 0.6-0.7) and 0.90 (95% CI = 0.82-0.99) 180 days after discharge. Quality of life and self-rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.

Predicting 30-Day Readmissions in an Asian Population: Building a Predictive Model by Incorporating Markers of Hospitalization Severity

“…The biggest driver of healthcare cost remains inpatient cost and the average cost of a bed day in Singapore in 2009 was USD 623[1]. The potential cost savings are huge if readmission reduction programs are successful.…”

“…There is great interest to develop a sustainable healthcare system that is future proof for the aging population. Several transitional care programs are already successful in reducing readmission rates [1,16], but these are more criteria driven in patient selection rather than targeted at patients at highest risk of readmission. Consequently, there is a need to identify predictors of readmission risk to derive a predictive model that can guide patient selection for these resource intensive programs.…”

Post-hospitalization transition to home: Patient perspectives of a personalized approach

“…Coaching and goal setting have demonstrated success in increasing patient activation levels. [8,30,31] Patients described the goal setting as improving their accountability for their own recovery and the sense of accomplishment which ensued upon attainment of the goal. This is an important component for teaching self-management skills to patients.…”

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

“…The current length of stay in public hospitals averages 6 days [33]. However, vulnerable older persons with complex care needs and limited social support experienced two‐ to threefold longer stays [22]. Therefore, one of the main efforts in linking acute and community health services is to adapt and implement effective TC programmes to reduce unnecessary rehospitalizations and optimize health for vulnerable older people [22,36].…”

“…However, vulnerable older persons with complex care needs and limited social support experienced two‐ to threefold longer stays [22]. Therefore, one of the main efforts in linking acute and community health services is to adapt and implement effective TC programmes to reduce unnecessary rehospitalizations and optimize health for vulnerable older people [22,36]. Following the initial optimism [35] and promising evidence from a national demonstration programme [22], there has been a proliferation of other TC programmes funded by the Ministry of Health [37].…”