Journal of General Internal Medicine

, Volume 29, Issue 11, pp 1460–1467

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

  • Honora Englander
  • Leann Michaels
  • Benjamin Chan
  • Devan Kansagara
Original Research

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.

KEY WORDS

care transitions patient readmission underserved populations health care reform 

Supplementary material

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

REFERENCES

  1. 1.
    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.PubMedCrossRefGoogle Scholar
  2. 2.
    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.PubMedCrossRefGoogle Scholar
  3. 3.
    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.PubMedCrossRefGoogle Scholar
  4. 4.
    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.PubMedCrossRefGoogle Scholar
  5. 5.
    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.PubMedCrossRefGoogle Scholar
  6. 6.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Kansagara D, Ramsay RS, Labby D, Saha S. Post-discharge intervention in vulnerable, chronically ill patients. J Hosp Med. 2012;7(2):124–130.PubMedCrossRefGoogle Scholar
  8. 8.
    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.PubMedCrossRefGoogle Scholar
  9. 9.
    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.Google Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    To access the appendix, click on the appendix link in the box to the right of the article online.Google Scholar
  16. 16.
    Oregon hospital discharge data set, owned by Oregon Health Authority and the Oregon Association of Hospitals & Health Systems. Accessed 5 Apr 2013.Google Scholar
  17. 17.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    OHSU EPIC Research data warehouse (RDW). Accessed 31 Jan 2012.Google Scholar
  19. 19.
    Oregon state vital records, Oregon health authority center for health statistics. Accessed 7 Feb 2013 via written request.Google Scholar
  20. 20.
    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.Google Scholar
  21. 21.
    Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245–1251.Google Scholar
  22. 22.
    Health commons grant. http://www.healthcommonsgrant.org/.
  23. 23.
    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.PubMedCrossRefGoogle Scholar
  24. 24.
    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.PubMedCrossRefGoogle Scholar
  25. 25.
    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.PubMedCrossRefGoogle Scholar
  26. 26.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363(3):297–298.PubMedCrossRefGoogle Scholar
  28. 28.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    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.CrossRefGoogle Scholar
  30. 30.
    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.PubMedCrossRefGoogle Scholar
  31. 31.
    Baicker K, Finkelstein A. The effects of Medicaid coverage–learning from the Oregon experiment. N Engl J Med. 2011;365(8):683–685.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    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.CrossRefGoogle Scholar
  34. 34.
    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.Google Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Honora Englander
    • 1
    • 2
  • 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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