Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting

Abstract

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations--The Care Transitions Intervention--could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

Transitional Care Interventions Prevent Hospital Readmissions For Adults With Chronic Illnesses

“…The trials were conducted in a broad variety of international health care systems. Eleven were from the United States; [26][27][28][29][30][31][32][33][34][35][36] three from Hong Kong; [37][38][39] two from Australia; 40,41 and one each from Germany, 42 Spain, 43 Canada, 44 Sweden, 45 the United Kingdom, 46 Ireland, 47 Italy, 48 China, 49 Taiwan, 50 and a collaboration between Spain and Belgium. 51 The studies' sample sizes ranged from 41 to 1,001 people.…”

“…Second, most 27,29,30,32,[34][35][36][37][38][39]42,43,45,[47][48][49]51 of the transitional care interventions that showed an effect on intermediate-and long-term readmissions lasted longer than thirty days and measured the intermediate-and long-term rates of readmission only after thirty days. These interventions could also have had an effect within the first thirty days, but this was not measured.…”

Preventing Hospitalizations in Children With Medical Complexity: A Systematic Review

“…Controlled studies of this intervention have revealed that combining postdischarge home visitation, selfcare, and health coaching activities for patients and caregivers has led to improvements in caregiver activation and self-management with reductions in cost and readmissions in the months after discharge. [45][46][47][48] Promising work that builds off the community health worker model 49 and nurse case management programs 50 have also led to reduced utilization after discharge. Refining and testing optimal home visit logistics, scope, and content as well as postdischarge activities are important next steps with the CMC population.…”

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study

“…[8][9][10][11] There are four components of the CTI: (1) medication management, (2) development of a personal health record that is carried from site to site, (3) close follow-up with a primary care provider and (4) the identification of 'red flags' and indications that would prompt patients to contact providers. An advanced practice nurse 'transition coach' performs post-discharge home visits and makes telephone calls, emphasising patient engagement and self-management in the care of chronic diseases.…”