The Care Transitions Intervention

Voss, Rachel K.; Gardner, Rebekah; Baier, Rosa R.; Butterfield, Kristen; Lehrman, Susan; Gravenstein, Stefan

doi:10.1001/archinternmed.2011.278

Cited by 167 publications

(51 citation statements)

References 10 publications

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“…Even wellvalidated programs, such as the Care Transitions Intervention®, have performed differently or required modifications to succeed in new venues. 51 Our study has several limitations. First, without access to claims data, we assess utilization only within CHA's network; we do not observe out-of-network readmissions, estimated to comprise 20 % of all readmissions.…”

Section: Discussionmentioning

confidence: 91%

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%

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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“…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%

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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“…[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.…”

Section: Care Transitions Interventionmentioning

confidence: 99%

“…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. The programme has been studied in several different acute care settings and has shown statistically significant reductions in 30-day readmission rates (4-6%) [8][9]11 and 90-day readmission rates (6-22%).…”

Section: Care Transitions Interventionmentioning

confidence: 99%

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

Sahota

Pulikottil-Jacob

Marshall

et al. 2016

Health Serv Deliv Res

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(2016) 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. Health Services and Delivery Research, 4 (7). ISSN 2050-4357 Access from the University of Nottingham repository: http://eprints.nottingham.ac.uk/33469/1/Sahota%20Health%20Serv%20Del%202016.pdf Copyright and reuse:The Nottingham ePrints service makes this work by researchers of the University of Nottingham available open access under the following conditions. This article is made available under the University of Nottingham End User licence and may be reused according to the conditions of the licence. For more details see: http://eprints.nottingham.ac.uk/end_user_agreement.pdf A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription.For more information, please contact eprints@nottingham.ac.uk This report should be referenced as follows: This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/). HEALTH SERVICES AND DELIVERY RESEARCHEditorial contact: nihredit@southampton.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk Criteria for inclusion in the Health Services and Delivery Research journalReports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programmeThe Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012.The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services.For more information about the HS&DR programme please visit the webs...

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The Care Transitions Intervention

Abstract: The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.

Cited by 167 publications

References 10 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

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

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