Journal of General Internal Medicine

, Volume 29, Issue 11, pp 1460–1467 | Cite as

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

  • Honora EnglanderEmail author
  • Leann Michaels
  • Benjamin Chan
  • Devan Kansagara
Original Research



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.


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


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


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


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.


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.


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).


C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.


care transitions patient readmission underserved populations health care reform 



This work was funded by Oregon Health & Science University, which had no role in the study design or interpretation of results. Funding (Appendix D 15) included evaluation funds, salary for nurse and pharmacy care, and payment to community partners for primary care for uninsured patients who lacked a usual source of care.4

Dr. Kansagara is funded by the Department of Veterans Affairs. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the US government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs.

Results described in this manuscript were presented at the Northwest Regional SGIM meeting in February 2013.

The authors would like to thank members of the C-TraIn Implementation and Research Team who contributed to the work described in this manuscript, including:

• Transitional Care Nurses: Stephanie Peña, Stacey Moultrie

• Pharmacy: Jackie Sharpe, Julie Kidd, Katie Foster, Daniel Kennedy

• Outpatient clinics: Kristy Butler, Lorri Aldridge, Paige Perry, Katie Bensching, Nic Granum, Carol Weber, Amanda Luocks, Billie Kay Stafford, Sandy Anderson, Rachel Solotaroff, Glory Coates, Ivan Wong, Ann Turner

• Clinical Informatics: Anita Murrin

• Hospital Administration: Char Riley, Peter Rapp, Marcha Hunt, Debbie Lamberger, Mayla Gant, Kippi Coffey, Desember Brucker, Jennifer Norquist

• Research Staff and Support: Chad Johnson, Chris Toomey, Christiane Winters, Katelynne Gardner, Sherry Kim, Russell Voth

• Advisors: Cynthia Morris, K. John McConnell, Christina Nicolaidis

Conflict of Interest

The authors declare that they do not have a conflict of interest.

IRB Approval

This study was approved by OHSU’s IRB (eIRB 6208). The full protocol can be accessed upon request to: Honora Englander, MD,

Supplementary material

11606_2014_2903_MOESM1_ESM.docx (87 kb)
ESM 1 (PDF 87.0 KB)


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Honora Englander
    • 1
    • 2
    Email author
  • Leann Michaels
    • 3
  • Benjamin Chan
    • 4
  • Devan Kansagara
    • 1
    • 5
  1. 1.Department of MedicineOregon Health & Science UniversityPortlandUSA
  2. 2.Old Town Clinic, Central City ConcernPortlandUSA
  3. 3.Oregon Rural Practice-based Research NetworkOregon Health & Science UniversityPortlandUSA
  4. 4.Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandUSA
  5. 5.Department of MedicineVeterans Affairs Medical CenterPortlandUSA

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