Studies evaluate transition care programs for patients leaving hospital

Programs designed to support the care of older patients as they make the transition from the hospital to outside clinicians and healthcare settings are associated with reduced rates of hospital readmissions, according to 2 reports in the July 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

In the first article, Rachel Voss, MPH, of Quality Partners of Rhode Island, Providence, and colleagues examined the effects of the Care Transitions Intervention randomized controlled trial in a real-world setting to test its effectiveness in reducing hospital readmissions. The intervention occurred over 30 days and included a coach who completed a hospital visit, a home visit, and 2 follow-up telephone calls with the patient.

The authors said the intervention program appears to be effective in real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open healthcare settings.

In the second article, Brett D. Stauffer, MD, MHS, of the Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, evaluated a transitional care program for patients 65 years and older with heart failure who were discharged from Baylor Medical Center Garland (BMCG) from August 2009 through April 2010. The program, led by advanced practice nurses, included a predischarge intervention by the advanced practice nurse and at least 8 post-discharge house calls per patient. The study examined the association between the transitional program and the 30-day (from discharge) all-cause readmission rate, as well as length of stay. It also compared the 60-day (from admission) direct cost for BMCG with that of other hospitals within the Baylor Health Care System.

Preliminary results suggest that transitional care programs reduce 30-day readmission rates for patients with heart failure, the authors concluded. “This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals,” they said.