Transitional Care Interventions Research Articles

Predischarge Provider Visits as a Method of Improving Transitional Care Clinic Visit Rates.

Transitional care interventions have been associated with reduced 30-day patient readmission, better quality of health care, and lower emergency department visits and health care costs. Transition Services at a major quaternary care center was underutilized by patients who were referred to the program. A pre-/postimplementation evaluation design was used to evaluate a quality improvement intervention. A face-to-face meeting between eligible patients and a Transition Services provider prior to patients being discharged from the hospital was evaluated as a process improvement intervention. The primary outcome was initial appointment attendance at the Transition Services clinic following hospital discharge. There was no statistically significant difference (P = .59) in patients' initial appointment attendance at Transition Services between the preintervention (48.1%) and intervention phases (54.8%). Provider engagement during hospitalization did not increase initial appointment attendance at Transition Services. Other strategies to improve Transition Services attendance rates are needed.

Reducing Hospitalizations and Emergency Department Visits in Patients With Venous Thromboembolism Using a Multicomponent Care Transition Intervention.

Preventing utilization of hospital and emergency department after diagnosis of venous thromboembolism is a complex problem. The objective of this study is to assess the impact of a care transition intervention on hospitalizations and emergency department visits after venous thromboembolism. We randomized adults diagnosed with a new episode of venous thromboembolism to usual care or a multicomponent intervention that included a home pharmacist visit in the week after randomization (typically occurring at time of discharge), illustrated medication instructions distributed during home visit, and a follow-up phone call with an anticoagulation expert scheduled for 8 to 30 days from time of randomization. Through physician chart review of the 90 days following randomization, we measured the incidence rate of hospital and emergency department visits for each group and their ratio. We also determined which visits were related to recurrent venous thromboembolism, bleeding, or anticoagulation and which where preventable. We enrolled 77 intervention and 85 control patients. The incidence rate was 4.50 versus 6.01 visits per 1000 patient days in the intervention versus control group (incidence rate ratio = 0.71; 95% confidence interval = 0.40-1.27). Most visits in the control group were not related to venous thromboembolism or bleeding (21%) and of those that were, most were not preventable (25%). The adjusted incidence rate ratio for the intervention was 1.05 (95% confidence interval = 0.57-1.91). Our patients had a significant number of hospital and emergency department visits after diagnosis. Most visits were not related to recurrent venous thromboembolism or bleeding and of those that were, most were not preventable. Our multicomponent intervention did not decrease hospitalizations and emergency department visits.

An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A feasibility study.

Background:Stroke is the leading cause of death and adult disability in Canada. Eighty percent of older adults (≥65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation. The transition between hospital and home is often fragmented, leading to adverse health outcomes, hospital readmissions, and increased health-care costs. This study examined the feasibility of a 6-month integrated transitional care stroke intervention (TCSI), and explored its effects on health outcomes, patient and provider experience, and cost in 30 community-living older adults (≥55 years) with stroke and multimorbidity (≥2 chronic conditions) using outpatient stroke rehabilitation services.Methods:The TCSI is a 6-month intervention delivered by an interprofessional (IP) team (occupational therapist, physiotherapist, speech language pathologist, registered nurse, social worker). It involved care coordination, home visiting, and IP case conferences, supported by a web-based application. A qualitative descriptive approach was used to explore the feasibility of implementing the intervention. A prospective one-group pretest/posttest was used to evaluate the effects of the intervention on health outcomes and use and costs of health services, from baseline to 6 months.Results:Participants had an average of eight comorbid conditions. The intervention was feasible and acceptable to both older adults and providers. From baseline to 6 months, there was no statistically significant difference in health outcomes. However, there was a significant reduction in the total per person use and costs of health services.Conclusions:This study established the feasibility of conducting a larger randomized controlled trial of this intervention.

The Experience of Providing Older Adult Patients with Transitional Care from an Acute Care Hospital to Home in Cooperation with a Public Health Center.

BackgroundThis study aimed to describe the experience of providing older adult patients with transitional care from an acute care hospital to home in cooperation with a public health center, in order to present the barriers to that care and suggest better organizational methods.MethodsThis was a cross-sectional study to show the results of the Geriatric Screening for Care-10 (GSC-10) and outcomes of transitional care. Among 659 hospitalized patients aged 65 years or above who lived in an administrative district, forty-five subjects were enrolled between June 24, 2019 and January 23, 2020. Within 48 hours of admission, using the 10 areas of GSC-10, they were assessed for cognitive impairment, depression, polypharmacy (5 or more medications), functional mobility, dysphagia, malnutrition, pain, and incontinence, and were reassessed before discharge. The transitional care plan (containing the treatment summary, the results of the GSC-10 assessment, and the post-discharge plan) was forwarded to a representative of the public health center, who provided continued disease management and various health care services, such as chronic disease and frailty care, and physical rehabilitation.ResultsOf all the participants, 64.4% had more than 1 GSC-10 concern. The most prevalent concerns were functional immobility (35.6%) and polypharmacy (22.2%). About 15.6% of the participants were readmitted to a nursing home or hospital. A total of 38 participants received the transitional care intervention. They received an average of 2.7 administered interventions. However, the rate of rejection was high (30.1%) and patients were visited an average of 16.5 days after discharge.ConclusionThrough our experience of providing transitional care from an acute care hospital to home in cooperation with a public health center, we expect that the transitional care suitable for the Korean medical situation could be established and successful.

A Literature Review on the Benefits for an Interprofessional Educational Program to Increase Novice Nurse Awareness of Case Management in Heart Failure.

The purpose of this literature review is to examine the potential value for an interprofessional education program to increase novice nurse awareness of case management in heart failure (HF). Acute care health care settings involving novice nurses. Evidence demonstrates that interprofessional collaboration on transitional care interventions for HF patients reduces 30-day readmissions. Implementation of an interprofessional education program for novice nurses can be an effective intervention to decrease readmissions by increasing knowledge of the nurse case manager role and development of interprofessional relationships. Increased awareness of HF case management is important for novice nurses. Understanding the nurse case manager role and early interprofessional collaboration can improve patient health outcomes among the HF population. Therefore, an education program to build confidence and strengthen interprofessional partnership in HF case management for the novice nurse is warranted.

Trabajadora de Salud, a care transitions intervention, for Latinas/os with brain injuries: Three case examples

ABSTRACTWith implementation of Centers for Medicare and Medicaid’s Hospital Readmissions Reduction Program, which lowers payments to hospitals with high 30-day readmission rates, hospitals have a financial incentive to improve hospital-to-home care transitions. Brain injury is a leading cause of 30-day hospital readmissions. Traditional discharge planning has not met the needs of brain injury survivors and caregivers especially Latinas/os whom experience worse rates of depression and caregiver burden. Trabajadora de Salud, a bilingual, bicultural, 90-day home visitation, family-focused, care transitions intervention, has demonstrated efficacy in improving outcomes among Latinas/os with brain injuries and their caregivers. This study described three case examples from the intervention to illustrate common needs among Latinas/os with brain injuries and methods of intervention.

Unmet Needs of US Acute Stroke Survivors Enrolled in a Transitional Care Intervention Trial

Background: Needs of patients that go unmet after a stroke can compromise the speed and extent of recovery. While unmet needs in long-term survivors has been studied, less is known about the unmet needs of acute stroke survivors. We examine unmet needs in the immediate postdischarge period among 160 participants in the (blinded for review) a transitional care intervention conducted in (blinded for review [1 US state]) during 2016 and 2017. Methods: Bivariate and multivariate analyses using Poisson models were used to examine the relationship between total number of unmet needs and demographics, stroke type and severity, stroke effects, and stroke risk factors. Results: The mean number of unmet needs was 4.55; number of unmet needs ranged from 2 to9; all participants had some unmet need. The most common unmet needs were stroke education (73.8%), financial (33.8%), and health-related (29.4%). In the final multivariate model income and education were inversely associated with number of unmet needs. As total number of stroke effects increased, so did number of unmet needs. Demographic variables (age, gender, and race), stroke risk factors, stroke type, and stroke severity were not statistically significantly associated with the number of unmet needs. Conclusions: These results identify that in the acute post discharge period stroke survivors have many unmet needs that range from physical to psychosocial. Targeting interventions to those with the potential for greater numbers of unmet needs might be a salient clinical approach to improving stroke recovery and rehabilitation.

What does it take to scale-up a complex intervention? Lessons learned from the Connect-Home transitional care intervention.

To discuss the multiple phases of research done to plan for wide-scale implementation (i.e. scale-up) of Connect-Home, a complex nurse-develop intervention. Barker et al.'s (Implementation Science, 2016, 11, 12) framework for intervention scale-up is applied to address the methods used to answer the following four questions: 'Who' needs to be involved in scale-up? 'What' intervention and implementation strategies need to be taken to scale? 'How' will scale-up be achieved? And what contextual factors influence 'when' scale-up is or is not successful? Discussion paper. Data sources include the experience of our research team, supported by literature and theory. The Connect-Home team conducted multiple research studies to plan for Connect-Home scale-up. Early studies (2008-2015) focused on formative work to design the Connect-Home intervention. Recent studies have involved successive pilot tests of Connect-Home's effectiveness, implementation, and scale-up (2015-2019). This article describes a systematic approach that nurse researchers can apply to plan for taking their interventions to scale. Planning for scale-up early in the process of intervention development is essential to speeding the translation of effective interventions into wide-scale practice. This article details the methods that nursing researchers applied to develop and test the strategies needed to plan for taking a complex intervention to scale across multiple settings. The methods described are applicable to nursing and other health researchers' development and scale-up of any complex intervention.

Emergency Department Encounters, Hospitalizations and ED Reliance Among Medicaid Eligible Patients with Sickle Cell Disease in North Carolina

Introduction: Sickle cell disease (SCD) is a complex disease for which pain is the hallmark. Pain from vaso-occlusive episodes is the number one reason for ED visits and hospital admissions. This paper reports Medicaid claims data from NC for individuals with SCD, including: 1) ED encounters and re-encounters within 7, 14 and 30 days; 2) hospitalization and re-hospitalization within 7, 14 and 30 days; and 3) ED reliance (EDR) score. Methods: We examined Medicaid claims data from for patients with a diagnosis of SCD (ICD 9 CM codes: 282.6x, ICD 10 CM codes: D57.0x, D57.1, D57.2x, D57.4x, D57.8x) in North Carolina. Data is reported for a cohort of 2,790 patients with a diagnosis of SCD, age 1 to 65+ and enrolled at least 11 months in NC Medicaid between March 1, 2016 and February 28, 2017. ED re-encounters and re-hospitalizations within 7, 14 and 30 days were identified using the time between the date of service listed on the ED or hospital claim and the next date of service in the subsequent claim. Individual ED Reliance (EDR) score was calculated as the total number of ED encounters divided by the total ambulatory visits (outpatient + ED encounters) per enrollee, (ambulatory visits reported elsewhere). Similar to Kroner et al, an EDR of >0.33 was considered a high score. Inpatient claims were identified using a category of service code indicating hospitalization. Results: The participants in the sample (n=2790) were majority female (57.92%), lived in metropolitan areas (77.63%) and had a mean age of 23.05 years old (SD=16.06). Of the 9,075 total ED encounters, 69.86% of the total sample had an ED encounter during the 12-month study period. There was a mean of 3.25 (SD=7.38) and median of 1 (IQR = 0 - 3) ED encounters per patient for the sample. Those who were 18-30 years old had the highest mean and median ED encounters per patient (4.98, SD= 9.34 and 2, IQR 1 to 5). The 31-45 year old group had the second most, with 4.82 (SD= 11.03) total ED encounters. The percentage of the sample with an ED re-encounter within 7, 14, and 30 days was also highest among the 18-30 year old group (29.17%, 33.98% and 40.89%) followed by those 31-45 years old (23.71%, 28.49%, and 34.80%), respectively. The 31-45 age group had the second most hospitalizations/patient and re-hospitalizations. The mean EDR was highest among 18-30 year old patients (0.35) and 46.48% of this age group had an EDR of 0.33 or greater. In the 31-45 year-old age group, the mean EDR was 0.28 and 35.18% had an EDR of 0.33 or greater. The overall sample had a mean of 1.30 (SD= 2.75) hospitalizations/patient. The 18-30 year old age group also had the highest mean total hospitalizations (2.08, SD= 3.72) and mean re-hospitalizations within 7 (0.16; SD=0.77), 14 (0.41; SD=1.68), and 30 (0.82; SD=2.79) days. The 31-45 age group had the second most hospitalizations/patient and re-hospitalizations (Table 1). Conclusions: Overall, increasing age coincided with increased ED and inpatient utilization, as well as with the period of transition from pediatric to adult SCD care. Furthermore, high EDR was most prevalent in the 18-30 age group. Our study further supports the need for increased focus on acute care utilization in the 18-45 year-old age group and considerations for improved care transition interventions. Disclosures Tanabe: NIH: Research Funding; AHRQ: Research Funding. Shah:Novartis: Consultancy, Research Funding, Speakers Bureau; Alexion: Speakers Bureau; GBT: Research Funding.

A FRAMEWORK FOR CARE TRANSITIONS FOR OLDER ADULTS WITH COMPLEX HEALTH CONDITIONS

For older adults with complex health conditions, transitions between care settings are common and a major risk to quality of care and patient safety. Care transition interventions have shown positive impacts on continuity of care and health service use, however, most require additional human resources (e.g., transition coach), focus on one transition or “handoff”, and provide support for individual patients without addressing underlying challenges of health system integration. We sought to develop a framework for system-level enhancements to care transitions for older adults. We report a secondary framework analysis of an ethnographic investigation (the “InfoRehab” project) of care transitions for older persons who had experienced a hip fracture. The ethnographic study involved interviews, observations, and document reviews for 23 patients, 19 family caregivers, and 92 health care providers. Data were collected at each transition point (1-4/patient) along the care continuum, at three Canadian sites (large urban, mid-size urban, rural). Our framework analysis followed the approach described by Gale et al. (2013), using as cases 12 peer-reviewed papers which had reported InfoRehab results. Two researchers coded findings from each paper, then developed an analytical framework of eight themes by consensus; these include: patient involvement and choice, family caregiver involvement, patient complexity, health care provider coordination, information sharing, documentation, system constraints, and relationships. NVivo 11 was used to index findings into these themes and to generate a matrix. We are working with system stakeholders, including patients and caregivers, to apply this framework in the development of improved systems for care transitions.

CHILDREN CAREGIVERS’ EXPERIENCES OF OLDER ADULTS WITH DEMENTIA IN CARE TRANSITION: A QUALITATIVE SYSTEMATIC REVIEW

Background/Purpose: Young and adult children have experienced caring for people who have been diagnosed with dementia. Caregiving needs affect family members who become the primary caregivers in care transition from hospital to home. This study aims to synthesize primary qualitative research on the experiences of children caregivers of older adults with dementia. Method: This is a systematic review describing young and adult child caregivers’ experiences in caring for patient with dementia in home-based care. Data sources were published literature written in English from CINAHL, Scopus, PubMed, and PsychoINFO (published from January 1976 to October 2018). The thematic synthesis approach was also applied to generate theory generating meta-synthesis research (TGMS). and to describe the process of caring for demented patients by caregivers. Result: Eight primary studies reporting 388 potential studies were included. Four themes emerged: 1) well-being which included encouraging and destructive well-being; 2) role transition which included positive or negative role transformations; 3) caregiver needs which included medical and nursing information or knowledges and health care services/community services; and 4) the challenge of dementia which included symptoms of dementia which were impairing. Conclusion The findings of this meta-synthesis study support evidence of well-being among adult children in caring for people with dementia in transition phases. We present thematic synthesis that could be useful to professionals working with caregivers and patients with dementia. We suggest that research importance should shift towards the development and evaluation of care transitions intervention, especially professionals preparing support after diagnosis.

AN INTEGRATED TRANSITIONAL CARE MODEL FOR OLDER ADULTS WITH MULTIMORBIDITY AND DEPRESSIVE SYMPTOMS

This pragmatic randomized controlled trial examined the implementation, effectiveness and costs of a nurse-led transitional care intervention to improve hospital-to-home transitions for 127 older adults (≥ 65 years) with depressive symptoms and multimorbidity in three Ontario communities. Participants were randomly allocated to receive the intervention plus usual care (n=63) or usual care alone (n=64). The intervention included an average of 5 in-home visits and 6 phone calls from a Registered Nurse (RN) over a 6-month period. The RN provided system navigation, patient education, medication review, and management of depressive symptoms and chronic conditions. Implementation outcomes included engagement rate, intervention dose, and feasibility of intervention implementation. Effectiveness outcomes included quality of life, depressive symptoms, anxiety, social support, and health and social service use and costs. Participants were an average of 76 years and had an average of 8 chronic conditions. Findings suggest that the intervention was feasible and acceptable to participants and providers. Intention-to-treat analyses using ANCOVA models showed no statistically significant group differences for the outcomes. However, the upper 95% confidence interval for the mean group difference showed greater clinically significant improvements in physical functioning in the intervention group. Quantile regression showed that the intervention may result in greater improvements in physical functioning for individuals with low to average physical functioning values compared to the control group. The intervention may also result in higher levels of perceived social support for individuals with a range of social support values. No statistically significant group differences were observed for service use or costs.

Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial.

Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. Trial Number NCT01918891.

Prediction of acute care service utilization for patients with hematologic malignancies.

312 Background: Improving the ability to predict which patients are at increased risk for acute care services subsequent to hospitalization can lead to more effective interventions and quality care. This study evaluated the performance of risk models to predict 30-day acute service utilization among adult inpatients with newly diagnosed hematologic malignancies. The study explored the impact of medical complications on potentially preventable service utilization, aligned with specifications for proposed measure OP-35 from the CMS Hospital Outpatient Quality Reporting Program. Methods: The study included 933 unique adult patients admitted to four acute care inpatient facilities within a non-profit community based healthcare system during calendar years 2012 to 2017. Risk models integrated a comprehensive set of data elements using clinical information from electronic medical records and facility oncology registries. Predictive models were constructed using a multivariable logistic regression, with calculation of standardized coefficients to rank order variables with the greatest impact on unplanned readmissions. Exploratory data mining techniques were conducted to augment classification of at-risk patients. Results: The mean age of study participants was 65 years and 55.1% were male. In order of prevalence, the types of hematologic malignancy were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days after the index hospitalization (lymphoma = 23.1%, myeloma = 22.1%, leukemia = 18.6%). Among the risk models, the most influential predictors included initial length of stay, severity of illness, and consult for social work. Overall, 56.6% of patients who were readmitted within 30 days of hospitalization presented with one or more symptoms associated with the CMS medical complication measure, including cytopenia, infection, negative hydration, and/or pain. Conclusions: Optimizing quality care in a value-based health care environment requires proactive approaches such as risk prediction models for identifying patients who can benefit most from care transition interventions.

Effects of Transitional Care on Hospital Readmission and Mortality Rate in Subjects With COPD: A Systematic Review and Meta-Analysis.

Studies on the effect of transitional care on hospital readmissions have reported inconsistent findings, and the effect on mortality has not been reviewed systematically. This systematic review and meta-analysis of randomized controlled trials aims to examine the effect of transitional care interventions on COPD-related readmissions, all-cause hospital readmissions, and all-cause mortality rates in subjects with COPD. Electronic databases (CINAHL, Embase, Scopus, MEDLINE, Cochrane, PubMed, Web of Science, Airity, BMJ Respiratory Research Journal, and National Digital Library of Theses and Dissertations) were searched from inception to April 26, 2017. Online searches were conducted using key words and MeSH terms for COPD and transitional care. Entry terms for searching included chronic obstructive pulmonary disease, COPD, COPD transitional care or care transition, continuity of patient care, patient discharge, and patient transfer. The quality of the included trials was assessed using the Cochrane Collaboration tool. 13 randomized controlled trials met the inclusion criteria. Transitional care significantly reduced the risk of COPD-related readmissions (odds ratio = 0.599, 95% CI 0.421-0.852) and all-cause hospital readmissions (odds ratio = 0.720, 95% CI 0.531-0.978), but not that of all-cause mortality (odds ratio = 0.863, 95% CI 0.576-1.294) in subjects with COPD. The effects of transitional care on hospital readmissions were moderated by the duration of interventions, type of care providers, and use of telephone follow-up as an element of the intervention. There was a significant effect of transitional care on both COPD-related and all-cause hospital readmissions in subjects with COPD. Duration of interventions, type of care providers, and use of telephone follow-up appeared to moderate the beneficial effects of transitional care.

Individual and Organizational Factors Associated With Hospital Readmission Rates: Evidence From a U.S. National Sample.

Objective: Hospital readmission rate is an important indicator for assessing quality of care in the acute and postacute settings. Identifying factors that increase risk for hospital readmissions can aid in the recognition of potential targets for quality improvement efforts. The main objective of this brief report was to examine the factors that predict increased risk of 30-day readmissions. Method: We analyzed data from the 2013 National Readmission Database (NRD). Results: The main factors that predicted increased risk of 30-day readmission were number of chronic conditions, severity of illness, mortality risk, and hospital ownership. Unexpectedly, discharge from a for-profit hospital was associated with greater risk for hospital readmission in the United States. Discussion and Conclusion: These findings suggest that patients with severe physical illness and multiple chronic conditions should be the primary targets for hospital transitional care interventions to help reduce the rate of unnecessary hospital readmissions.

Implementation and evaluation of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: a feasibility study

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model

ABSTRACTBackground: Transitional care (TC) has been shown to improve stroke rehabilitation in discharged stroke patients. Previous TC interventions did not report satisfactory stroke rehabilitation outcomes or risk management. Incorporating a health behavior theory in interventions can effectively improve health behaviors and metabolic indicators.Objectives: This study was a clinical controlled trial to investigate the impact of the Integrated Behavioral Model (IBM)-based 3-month TC on health behaviors, clinical outcomes, and stroke knowledge in discharged elderly stroke patients.Methods: Sixty elderly patients were recruited from two wards of a public teaching hospital in China. To prevent potential treatment contamination, patients were allocated into either a control or intervention group depending on which wards they were admitted to. The TC intervention considered all the IBM constructs to provide patients assistance in implementing health behaviors as recommended by the Chinese stroke guidelines. The TC intervention commenced one day before discharge and lasted three months after discharge. A linear mixed model was used to measure the impact of the intervention.Results: The TC intervention improved the discharged elderly stroke patients’ health behaviors, activities of daily living, quality of life, and stroke knowledge. The intervention also controlled the patients’ systolic blood pressure, body mass index, total cholesterol, triglycerides, and low-density lipoprotein cholesterol.Conclusions: This study provided evidence of concurrent self-reported and objective clinical indicators in discharged elderly stroke patients for the impact of the IBM-based 3-month TC intervention, which can be recommended for clinical practice.

Transitional care intervention effects on mortality and healthcare utilisation: a systematic review of pragmatic trials.

Transitions in care for patients with chronic conditions are often complex, leading to increased mortality and healthcare utilisation. Systematic reviews on effectiveness of transitional care (TC) interventions are inconclusive and none to date have examined pragmatic randomised controlled trials (RCTs) specifically. We aimed to determine the effectiveness of the components of TC interventions on mortality and healthcare …

Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial

BackgroundCoordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications.MethodsIn a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation.DiscussionWhile HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care.Trial registrationClinicalTrials.gov NCT02689076. “Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization.” Registered 23 February 2016.