Skip to main content
Erschienen in: Journal of General Internal Medicine 11/2014

01.11.2014 | Original Research

The Care Transitions Innovation (C-TraIn) for Socioeconomically Disadvantaged Adults: Results of a Cluster Randomized Controlled Trial

verfasst von: Honora Englander, MD, Leann Michaels, BS, Benjamin Chan, MS, Devan Kansagara, MD, MCR

Erschienen in: Journal of General Internal Medicine | Ausgabe 11/2014

Einloggen, um Zugang zu erhalten

Abstract

Background

Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions.

Objective

To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality.

Design

Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon.

Participants

Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance.

Intervention

Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement.

Measurements

Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded.

Results

There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30–3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p = 0.02).

Conclusions

C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.
Anhänge
Nur mit Berechtigung zugänglich
Literatur
1.
Zurück zum Zitat Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;43(3):246–255.PubMedCrossRef Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;43(3):246–255.PubMedCrossRef
2.
Zurück zum Zitat Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):433–440.PubMedCrossRef Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):433–440.PubMedCrossRef
3.
Zurück zum Zitat Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549–555.PubMedCrossRef Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549–555.PubMedCrossRef
4.
Zurück zum Zitat Englander H, Kansagara D. Planning and designing the care transitions innovation (C-train) for uninsured and medicaid patients. J Hosp Med. 2012;7(7):524–529.PubMedCrossRef Englander H, Kansagara D. Planning and designing the care transitions innovation (C-train) for uninsured and medicaid patients. J Hosp Med. 2012;7(7):524–529.PubMedCrossRef
5.
Zurück zum Zitat Kangovi S, Barg FK, Carter T, et al. Challenges faced by patients with low socioeconomic status during the post-hospital transition. J Gen Intern Med. 2014;29(2):283–289.PubMedCrossRef Kangovi S, Barg FK, Carter T, et al. Challenges faced by patients with low socioeconomic status during the post-hospital transition. J Gen Intern Med. 2014;29(2):283–289.PubMedCrossRef
6.
Zurück zum Zitat Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230–241.PubMedCrossRefPubMedCentral Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230–241.PubMedCrossRefPubMedCentral
7.
Zurück zum Zitat Kansagara D, Ramsay RS, Labby D, Saha S. Post-discharge intervention in vulnerable, chronically ill patients. J Hosp Med. 2012;7(2):124–130.PubMedCrossRef Kansagara D, Ramsay RS, Labby D, Saha S. Post-discharge intervention in vulnerable, chronically ill patients. J Hosp Med. 2012;7(2):124–130.PubMedCrossRef
8.
Zurück zum Zitat Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.PubMedCrossRef Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.PubMedCrossRef
9.
Zurück zum Zitat US Congress. House Committee on Ways and Means, Committee on Energy and Commerce, Committee on Eduction and Labor. Compilation of Patient Protection and Affordable Care Act: as amended through 1 November 2010, including Patient Protection and Affordable Care Act health-related portions of the Health Care and Education Reconciliation Act of 2010. Washington, DC: US Government Printing Office; 2010:Xxii. US Congress. House Committee on Ways and Means, Committee on Energy and Commerce, Committee on Eduction and Labor. Compilation of Patient Protection and Affordable Care Act: as amended through 1 November 2010, including Patient Protection and Affordable Care Act health-related portions of the Health Care and Education Reconciliation Act of 2010. Washington, DC: US Government Printing Office; 2010:Xxii.
10.
Zurück zum Zitat Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528.PubMedCrossRef Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528.PubMedCrossRef
11.
Zurück zum Zitat Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.PubMedCrossRef Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.PubMedCrossRef
12.
Zurück zum Zitat Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187.PubMedCrossRefPubMedCentral Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187.PubMedCrossRefPubMedCentral
13.
Zurück zum Zitat Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675–684.PubMedCrossRef Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675–684.PubMedCrossRef
14.
Zurück zum Zitat Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649–1656.PubMedCrossRefPubMedCentral Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649–1656.PubMedCrossRefPubMedCentral
15.
Zurück zum Zitat To access the appendix, click on the appendix link in the box to the right of the article online. To access the appendix, click on the appendix link in the box to the right of the article online.
16.
Zurück zum Zitat Oregon hospital discharge data set, owned by Oregon Health Authority and the Oregon Association of Hospitals & Health Systems. Accessed 5 Apr 2013. Oregon hospital discharge data set, owned by Oregon Health Authority and the Oregon Association of Hospitals & Health Systems. Accessed 5 Apr 2013.
17.
Zurück zum Zitat Finkelstein A, Taubman S, Wright B, Bernstein M, Gruber J, Newhouse JP, Allen H, Baicker K, Oregon Health Study Group. The Oregon health insurance experiment: evidence from the first year. Q J Econ. 2012;127(3):1057–1106.PubMedCrossRefPubMedCentral Finkelstein A, Taubman S, Wright B, Bernstein M, Gruber J, Newhouse JP, Allen H, Baicker K, Oregon Health Study Group. The Oregon health insurance experiment: evidence from the first year. Q J Econ. 2012;127(3):1057–1106.PubMedCrossRefPubMedCentral
18.
Zurück zum Zitat OHSU EPIC Research data warehouse (RDW). Accessed 31 Jan 2012. OHSU EPIC Research data warehouse (RDW). Accessed 31 Jan 2012.
19.
Zurück zum Zitat Oregon state vital records, Oregon health authority center for health statistics. Accessed 7 Feb 2013 via written request. Oregon state vital records, Oregon health authority center for health statistics. Accessed 7 Feb 2013 via written request.
20.
Zurück zum Zitat Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373-383. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373-383.
21.
Zurück zum Zitat Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245–1251. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245–1251.
23.
Zurück zum Zitat Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.PubMedCrossRef Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.PubMedCrossRef
24.
Zurück zum Zitat Kangovi S, Mitra N, Grande D, White M, McCollum S, Sellman J, Shannon R, Long J. Patient-centered community HealthWorker intervention to improve posthospital outcomes. A randomized clinical trial. JAMA Intern Med. 2014;174:535–543. online first.PubMedCrossRef Kangovi S, Mitra N, Grande D, White M, McCollum S, Sellman J, Shannon R, Long J. Patient-centered community HealthWorker intervention to improve posthospital outcomes. A randomized clinical trial. JAMA Intern Med. 2014;174:535–543. online first.PubMedCrossRef
25.
Zurück zum Zitat Joynt KE, Gawande AA, Orav EJ, Jha AK. Contribution of preventable acute care spending to total spending for high-cost medicare patients. JAMA. 2013;309(24):2572–2578.PubMedCrossRef Joynt KE, Gawande AA, Orav EJ, Jha AK. Contribution of preventable acute care spending to total spending for high-cost medicare patients. JAMA. 2013;309(24):2572–2578.PubMedCrossRef
26.
Zurück zum Zitat van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183(7):E391–E402.PubMedCrossRefPubMedCentral van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183(7):E391–E402.PubMedCrossRefPubMedCentral
27.
Zurück zum Zitat Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363(3):297–298.PubMedCrossRef Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363(3):297–298.PubMedCrossRef
28.
Zurück zum Zitat Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587–593.PubMedCrossRefPubMedCentral Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587–593.PubMedCrossRefPubMedCentral
29.
Zurück zum Zitat Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013;32(7):1196–1203.CrossRef Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013;32(7):1196–1203.CrossRef
30.
Zurück zum Zitat Saha S, Solotaroff R, Oster A, Bindman AB. Are preventable hospitalizations sensitive to changes in access to primary care? The case of the Oregon health plan. Med Care. 2007;45(8):712–719.PubMedCrossRef Saha S, Solotaroff R, Oster A, Bindman AB. Are preventable hospitalizations sensitive to changes in access to primary care? The case of the Oregon health plan. Med Care. 2007;45(8):712–719.PubMedCrossRef
31.
32.
Zurück zum Zitat Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, Shintani A, Sponsler KC, Harris LJ, Theobald C, Huang RL, Scheurer D, Hunt S, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Bates DW, Williams MV, Schnipper JL. PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.PubMedCrossRefPubMedCentral Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, Shintani A, Sponsler KC, Harris LJ, Theobald C, Huang RL, Scheurer D, Hunt S, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Bates DW, Williams MV, Schnipper JL. PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.PubMedCrossRefPubMedCentral
33.
Zurück zum Zitat Kind AJ, Jensen L, Barczi S, et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff (Millwood). 2012;31(12):2659–2668.CrossRef Kind AJ, Jensen L, Barczi S, et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff (Millwood). 2012;31(12):2659–2668.CrossRef
34.
Zurück zum Zitat Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, Jaffe HA, Kalhan R, Pickard AS, Pittendrigh BR, Schatz B, Sullivan JL, Thomashow BM, Williams MV, Krishnan JA. Interventions to reduce rehospitalizations following chronic obstructive pulmonary disease exacerbations: a systematic review. Ann Am Thorac Soc. 2014;January. Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, Jaffe HA, Kalhan R, Pickard AS, Pittendrigh BR, Schatz B, Sullivan JL, Thomashow BM, Williams MV, Krishnan JA. Interventions to reduce rehospitalizations following chronic obstructive pulmonary disease exacerbations: a systematic review. Ann Am Thorac Soc. 2014;January.
Metadaten
Titel
The Care Transitions Innovation (C-TraIn) for Socioeconomically Disadvantaged Adults: Results of a Cluster Randomized Controlled Trial
verfasst von
Honora Englander, MD
Leann Michaels, BS
Benjamin Chan, MS
Devan Kansagara, MD, MCR
Publikationsdatum
01.11.2014
Verlag
Springer US
Erschienen in
Journal of General Internal Medicine / Ausgabe 11/2014
Print ISSN: 0884-8734
Elektronische ISSN: 1525-1497
DOI
https://doi.org/10.1007/s11606-014-2903-0

Weitere Artikel der Ausgabe 11/2014

Journal of General Internal Medicine 11/2014 Zur Ausgabe

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.