Journal of General Internal Medicine

, Volume 34, Issue 9, pp 1758–1765 | Cite as

Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial

  • David T. LissEmail author
  • Ronald T. Ackermann
  • Andrew Cooper
  • Emily A. Finch
  • Courtney Hurt
  • Nicola Lancki
  • Angela Rogers
  • Avani Sheth
  • Caroline Teter
  • Christine Schaeffer
Original Research



There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.


Evaluate effects of a transitional care practice (TC) that comprehensively addresses patients’ medical and psychosocial needs following hospital discharge.


Pragmatic, randomized comparative effectiveness trial.


Adults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care.


TC intervention included a scheduled post-discharge appointment at the TC practice, where a multidisciplinary team comprehensively assessed patients’ medical and psychosocial needs, addressed modifiable barriers, and subsequent linkage to a new primary care source. Routine Care involved assistance scheduling a post-discharge appointment with a primary care provider that often partnered with the hospital where the initial encounter occurred.

Main Measures

The primary outcome was a binary indicator of death or additional hospital encounters within 90 days of initial discharge. Secondary outcomes included any additional hospital encounters, and counts of hospital encounters, over 180 days.

Key Results

Four hundred ninety patients were randomized to TC intervention and 164 to Routine Care; 34.6% were uninsured, 49.7% had Medicaid, and 57.4% were homeless or lived in a high-poverty area. There was no significant difference between arms in the 90-day probability of death or additional hospital encounters (relative risk [RR] 0.89; 0.91; 95% confidence interval [CI] 0.74–1.13). However, TC patients had 37% and 35% lower probability of any inpatient admission over 90 days (RR 0.63; 95% CI 0.43–0.91) and 180 days (RR 0.65; 95% CI 0.47–0.89), respectively. Over 180 days, TC patients had 42% fewer inpatient admissions (incidence rate ratio 0.58; 95% CI 0.37–0.90).


Among patients randomized to a patient-centered transitional care intervention, there was no significant reduction in 90-day probability of death or additional hospital encounters. However, there were significant decreases in measures of inpatient admissions over 180 days.

Trial Registration identifier NCT03066492.


care transitions comparative effectiveness patient-centered care randomized trials vulnerable populations underserved populations hospital discharge 



We thank the patients who participated in this study, along with care team members and staff at the Northwestern Medical Group Transitional Care practice. We thank the Chicago-area FQHCs that provided care to patients in both study arms and AllianceChicago for collaboration in data acquisition efforts. We also recognize the support and participation of Northwestern Memorial HealthCare and providers and staff at Northwestern Memorial Hospital. We thank Dyanna Gregory, MS, who led early work on several aspects of study randomization and analysis, and Michelle Cates and Mya Carter, who conducted follow-up phone interviews.


This research was supported by funding from Northwestern Memorial Hospital and the J.B. and M.K. Pritzker Family Foundation. Funders were not involved in reviewing or approving the manuscript for publication. REDCap is supported at Feinberg School of Medicine by the Northwestern University Clinical and Translational Science (NUCATS) Institute. Research reported in this publication was supported, in part, by the National Institutes of Health’s National Center for Advancing Translational Sciences (#UL1TR001422).

Compliance with Ethical Standards

Protocols were registered in the National Clinical Trials Registry (NCT03066492) and approved by Northwestern University’s institutional review board with a waiver of informed consent for study inclusion and collection of electronic outcome data.

Conflict of Interest

Dr. Schaeffer, Ms. Rogers, and Ms. Teter report employment as health care providers at the Northwestern Medical Group Transitional Care (TC) practice, and Ms. Hurt formerly provided social work services at the Northwestern Medical Group TC practice. All remaining authors declare that they do not have a conflict of interest.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • David T. Liss
    • 1
    • 2
    Email author
  • Ronald T. Ackermann
    • 1
    • 2
  • Andrew Cooper
    • 1
    • 2
  • Emily A. Finch
    • 1
    • 2
  • Courtney Hurt
    • 3
  • Nicola Lancki
    • 2
  • Angela Rogers
    • 2
    • 4
  • Avani Sheth
    • 5
  • Caroline Teter
    • 2
    • 4
  • Christine Schaeffer
    • 2
    • 4
  1. 1.Center for Community Health, Institute for Public Health and MedicineNorthwestern University Feinberg School of MedicineChicagoUSA
  2. 2.Division of General Internal Medicine and Geriatrics Northwestern University Feinberg School of MedicineChicagoUSA
  3. 3.PCPI FoundationChicagoUSA
  4. 4.Northwestern Medical Group Transitional CareChicagoUSA
  5. 5.Department of Family and Community MedicineCook County Health and Hospitals SystemChicagoUSA

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