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Date of Study

October 26, 2004

Service Type

Target Populations

Key Outcomes

Return to Evidence Bank

Care Transitions Program

Citation: Coleman, E., Smith, J., Frank, J., Min, S., Parry, C., & Kramer, A. (2004). Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Journal of the American Geriatrics Society (JAGS), 52(11), 1817–1825. https://doi.org/10.1111/j.1532-5415.2004.52504.x

Objectives

To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce re-hospitalization rates.

Design

Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235).

Setting

A large integrated delivery system in Colorado.

Participants 

Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions.

Intervention

Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach.

Measurements

Rates of post-discharge hospital use at 30, 60, and 90 days. Intervention subjects’ care experience was assessed using the care transitions measure.

Results

The adjusted odds ratio comparing re-hospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28–0.96) at 30 days, 0.43 (95% CI=0.25–0.72) at 90 days, and 0.57 (95% CI=0.36–0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen.

Conclusion

Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.