Rachel K. Voss
The Care Transitions Intervention
Brown University|Providence College
background wellexecuted communication among hospital providers patients receiving providers time hospital discharge contributes better health outcomes lower overall health care coststhe care transitions intervention reduced 30day hospital readmissions 30 randomized controlled trial integrated health system requires realworld testing establish effectiveness settingswe hypothesized coaching would reduce 30day readmission rates feeforservice medicare beneficiaries even open urban health care delivery systemsmethods quasiexperimental prospective cohort studyfrom january 1 2009 june 30 2010 coaches recruited convenience sample feeforservice medicare patients 6 rhode island hospitals receive care transitions interventionwe paired coaching data medicare claims enrollment data used logistic regression compare odds 30day readmission intervention group vs internal external control groupsresults compared individuals receive part intervention 200readmission rate 30day readmissions fewer participants received coaching 128 odds ratio 061 95 confidence interval 042088individuals internal control group declined participate lost followup completing home visit readmission rates similar external control group 186 odds ratio 094 95 confidence interval 077114 conclusionsthe care transitions intervention appears effective realworld implementationthis finding underscores opportunity improve health outcomes beginning time discharge open health care settings