Devan Kansagara, MD, MCR

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.[1] Early studies showed that nurse‐led transitional care interventions beginning in the hospital and continuing after discharge had the potential to reduce the rate of hospital readmissions.[2, 3] Since then, the healthcare landscape has been evolving in important ways, with the spread of the electronic medical record, the patient‐centered medical home, and an increased push to health systems integration.[4, 5, 6]

The potential success or failure of transitional care interventions, which are inherently complex and can involve multiple components, may depend on the nature of the interventions themselves, the settings in which they were implemented, and/or the populations included. Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply.

The main aim of this article, culled from a larger report commissioned by the Veterans Health Administration (VHA)[7] was to catalogue which types of transitional care interventions hold promise and which populations have been best studied, to help health systems guide prioritization and adaptation of the most relevant transitional care activities and help focus future research efforts.

METHODS

We conducted a review of systematic reviews published in English, following Preferred Reporting Items for Systematic Reviews and Meta‐analyses reporting guideline for systematic reviews.[8] A protocol describing the review plan was posted to a public website before the study was initiated.[9] From an initial review of the literature, we recognized that most systematic reviews typically either examined different transitional care intervention types in a given patient population, or examined a given intervention type in a variety of patient populations. We use the term intervention type to refer to single‐ or multicomponent interventions that used a similar approach or bundle of care processes (eg, telemonitoring, hospital‐at‐home), or addressed a similar key process of the care transition (eg, medication reconciliation). Patient populations are defined according to clinical condition (eg, congestive heart failure) or demographic characteristics (eg, geriatric). Given that the review was originally commissioned by the VHA, we excluded pediatric and obstetric patient populations.

We identified categories of patient populations and intervention types with input from a panel of content experts, an initial scan of the literature, and with input from our study team to help guide our literature search (see Supporting Information, Appendix A, in the online version of this article). We searched PubMed and Cochrane databases of systematic reviews from database inception through May 2014.

We selected reviews that reported hospital readmissions as an outcome, regardless of whether it was the primary outcome. However, we summarized other outcomes reported by each review. Within each patient population or intervention type of interest, we first identified reviews that fulfilled key quality criteria: (1) clearly reported their search strategy, (2) reported inclusion and exclusion criteria, and (3) conducted an appraisal of the internal validity of the included trials.[10, 11] If there was more than 1 review within each category fulfilling these criteria, we prioritized the most recent review and those with the broadest scope. We discussed the ultimate choice of review as a group and resolved any disagreements through consensus. One author abstracted prespecified data from each review and a second author checked entries for accuracy (see Supporting Information, Appendix B, in the online version of this article).

We qualitatively synthesized the literature, using the categories of intervention type, patient population, and healthcare setting to organize our synthesis. We further identified common themes that cut across different intervention types and patient populations related to the following characteristics (derived from an existing taxonomy):[12] transition type (hospital to home, hospital to nursing facility), intervention target (patient, caregiver), key processes (education, personal health record), key personnel involved (nurse, social worker), method of postdischarge follow‐up (phone, home visits), and intensity and complexity. We developed brief narrative summaries of findings for each review. These narratives were compiled into a single document and reviewed independently by each of the authors of this report, who then compiled a brief list of key cross‐cutting themes in the evidence.

RESULTS

We reviewed 807 titles and abstracts from the electronic search, and identified an additional 94 from reviewing reference lists and performing manual searches for recently published and unpublished or ongoing studies (Figure 1). Eighty‐one systematic reviews met our inclusion criteria and, of these, we selected 17 that were the most recent and broadly scoped: 10 of intervention types (Table 1) and 7 of patient populations (Table 2).

Figure 1

DISCUSSION

We examined 17 systematic reviews across different patient populations representing a variety of intervention types to provide a broad overview of the care transitions literature. Variations in population studied, intervention definition, personnel, outcome definition, and setting make it difficult to identify strong evidence in support of a specific intervention type that should be broadly implemented. There were, however, some common themes that emerged across the literature suggesting that successful interventions addressed more aspects of the care transition, included the means to assess and respond to individual peridischarge needs, and included components that spanned care settings. In practical terms, the actualization of these themes has been accomplished in many interventions with the addition of transitional care personnel such as nurses and/or pharmacists. Additionally, interventions have often been tailored to the needs of individual patients with the use of needs assessment and patient‐centered personalized health records.[1]

Because there are many potential steps in the care transition, focusing on only 1 of these steps, such as medication reconciliation, is unlikely to have significant benefit on risk of readmission.[15] The pathways to readmission vary, as suggested both by the inability to accurately anticipate which patients will be readmitted,[28] and by case review studies characterizing underlying factors contributing to preventable readmissions.[29]

The problems with recommending that a specific intervention be broadly implemented include both the lack of evidence supporting such a recommendation and the likelihood that the transitional care gaps are not the same in all settings, or for all populations of patients treated. As health systems rapidly evolve, it may be useful for them to inventory strengths and weaknesses of their current approach to transitional care both to identify critical care gaps and to avoid investment in resource‐intensive transitional care interventions that may be redundant with existing activities.

Indeed, transitional care gaps may have changed over the last decade. Two large reviews showed that more recently published studies were less likely to have found an improvement in outcomes.[14, 24] In the years since some of the most successful and widely cited transitional care interventions were developed and evaluated, many health systems have undertaken major transformations, including the adoption of the patient‐centered medical home model and integration of electronic health records, which may implicitly address some earlier gaps. For instance, foundational qualitative work for the Care Transitions Measure identified discontinuities in information transfer as 1 of 4 major transitional care barriers identified by patients, and the personal health record was created, in part, to address this gap.[30] A shared electronic health record across healthcare settings has the potential to mitigate some of these concerns.

In general, there is an overarching need for better evidence to guide selection and implementation of complex, multicomponent transitional care interventions in different settings. There remain a number of gaps regarding the operationalization of interventions. For instance, the optimal choice of personnel, the comparative effects of home visits and other forms of postdischarge follow‐up, and the best approach to patient selection (whether through use of a formal readmission risk assessment model or a focus on populations with high‐risk comorbidities) are unknown.

One of the major weaknesses of the transitional care literature is the marked variation in intervention definitions, timing of outcome follow‐up, and descriptions of interventions and usual care. Use of taxonomies to guide study design and description may help standardize reporting.

Most of the care transitions literature has been hospital‐focused, and the interventions often extend hospital services beyond hospitalization. Given the growth of medical homes, it will be important to examine the effectiveness of outpatient‐based care transitions models that reach‐in to the hospital. Studies comparing approaches such as home‐visit and telephone‐based interventions, different risk‐prioritization schemes, and the use of different types of personnel are also needed.

There is very little literature examining transitional care interventions in patients with mental health conditions or undergoing surgery. A recent report for the Veterans Health Administration found that 24% of patients with chronic mental health conditions are readmitted within 30 days of discharge.[31] About 1 in 7 Medicare patients admitted to a surgical service is readmitted within 30 days.[32] The transitional care needs of these populations may differ substantially from medical populations and warrant further study.

Our review has a number of important limitations. Our overview of the literature was necessarily broad rather than in‐depth. There are many nuances in the results, internal validity, and generalizability of studies that are not represented in our overview. It was difficult to use established criteria to formally rate the strength of evidence for each of our conclusions, but we indicated strength of evidence ratings when reported in reviews. As we note in the results, our assessment of cross‐cutting themes is based largely on low‐strength evidence, given the indirect comparisons and the many factors that varied among the included studies. Our inclusion criteria specified readmissions as an outcome, but there are care transitions that focus exclusively on other outcomes, such as smoking cessation interventions around the time of discharge.[33] Furthermore, there are many outpatient‐based interventions designed to affect emergency room and hospital utilization that are not captured in our review, but may nevertheless be important to understanding the role of care coordination in the context of the medical home. We did not systematically update the included reviews' searches, and there may be more recent studies not represented here, though we are not aware of newer studies that would substantively change our summary of findings.

CONCLUSIONS

The literature includes many different types of interventions, studied in varied populations and clinical settings, and implemented in different ways. Furthermore, there are very little comparative effectiveness data. It is therefore difficult to conclusively identify specific intervention components and characteristics that are necessary for successful care transitions. Effective interventions are generally more comprehensive, address more aspects of the care transition, extend beyond the hospital stay, and have the flexibility to respond to individual patient needs. Transitional care interventions have not been well studied in integrated health system settings, or in mental health and surgical populations.

Disclosures: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the US government.

The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration (VHA) Project ESP 05‐225, VA#01‐0206. Dr. Jencks' work on this project was supported in part by a grant from the Quality Enhancement Research Initiative (05‐225), Department of Veterans Affairs. Dr. Jencks has reported prior consulting work with the following entities: Inovalon, Care Centrix, Affymax, Curaspan, Reinforced Care, Health Services Advisory Group, Delmarva Foundation, Connecticut Peer Review Organization, Maryland Health Services Cost Review Commission, Institute for Healthcare Improvement, American Association for Respiratory Care, Monaghan Medical, Iowa Society for Respiratory Care.

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.[1] Early studies showed that nurse‐led transitional care interventions beginning in the hospital and continuing after discharge had the potential to reduce the rate of hospital readmissions.[2, 3] Since then, the healthcare landscape has been evolving in important ways, with the spread of the electronic medical record, the patient‐centered medical home, and an increased push to health systems integration.[4, 5, 6]

The potential success or failure of transitional care interventions, which are inherently complex and can involve multiple components, may depend on the nature of the interventions themselves, the settings in which they were implemented, and/or the populations included. Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply.

The main aim of this article, culled from a larger report commissioned by the Veterans Health Administration (VHA)[7] was to catalogue which types of transitional care interventions hold promise and which populations have been best studied, to help health systems guide prioritization and adaptation of the most relevant transitional care activities and help focus future research efforts.

METHODS

We conducted a review of systematic reviews published in English, following Preferred Reporting Items for Systematic Reviews and Meta‐analyses reporting guideline for systematic reviews.[8] A protocol describing the review plan was posted to a public website before the study was initiated.[9] From an initial review of the literature, we recognized that most systematic reviews typically either examined different transitional care intervention types in a given patient population, or examined a given intervention type in a variety of patient populations. We use the term intervention type to refer to single‐ or multicomponent interventions that used a similar approach or bundle of care processes (eg, telemonitoring, hospital‐at‐home), or addressed a similar key process of the care transition (eg, medication reconciliation). Patient populations are defined according to clinical condition (eg, congestive heart failure) or demographic characteristics (eg, geriatric). Given that the review was originally commissioned by the VHA, we excluded pediatric and obstetric patient populations.

We identified categories of patient populations and intervention types with input from a panel of content experts, an initial scan of the literature, and with input from our study team to help guide our literature search (see Supporting Information, Appendix A, in the online version of this article). We searched PubMed and Cochrane databases of systematic reviews from database inception through May 2014.

We selected reviews that reported hospital readmissions as an outcome, regardless of whether it was the primary outcome. However, we summarized other outcomes reported by each review. Within each patient population or intervention type of interest, we first identified reviews that fulfilled key quality criteria: (1) clearly reported their search strategy, (2) reported inclusion and exclusion criteria, and (3) conducted an appraisal of the internal validity of the included trials.[10, 11] If there was more than 1 review within each category fulfilling these criteria, we prioritized the most recent review and those with the broadest scope. We discussed the ultimate choice of review as a group and resolved any disagreements through consensus. One author abstracted prespecified data from each review and a second author checked entries for accuracy (see Supporting Information, Appendix B, in the online version of this article).

We qualitatively synthesized the literature, using the categories of intervention type, patient population, and healthcare setting to organize our synthesis. We further identified common themes that cut across different intervention types and patient populations related to the following characteristics (derived from an existing taxonomy):[12] transition type (hospital to home, hospital to nursing facility), intervention target (patient, caregiver), key processes (education, personal health record), key personnel involved (nurse, social worker), method of postdischarge follow‐up (phone, home visits), and intensity and complexity. We developed brief narrative summaries of findings for each review. These narratives were compiled into a single document and reviewed independently by each of the authors of this report, who then compiled a brief list of key cross‐cutting themes in the evidence.

RESULTS

We reviewed 807 titles and abstracts from the electronic search, and identified an additional 94 from reviewing reference lists and performing manual searches for recently published and unpublished or ongoing studies (Figure 1). Eighty‐one systematic reviews met our inclusion criteria and, of these, we selected 17 that were the most recent and broadly scoped: 10 of intervention types (Table 1) and 7 of patient populations (Table 2).

Figure 1

DISCUSSION

We examined 17 systematic reviews across different patient populations representing a variety of intervention types to provide a broad overview of the care transitions literature. Variations in population studied, intervention definition, personnel, outcome definition, and setting make it difficult to identify strong evidence in support of a specific intervention type that should be broadly implemented. There were, however, some common themes that emerged across the literature suggesting that successful interventions addressed more aspects of the care transition, included the means to assess and respond to individual peridischarge needs, and included components that spanned care settings. In practical terms, the actualization of these themes has been accomplished in many interventions with the addition of transitional care personnel such as nurses and/or pharmacists. Additionally, interventions have often been tailored to the needs of individual patients with the use of needs assessment and patient‐centered personalized health records.[1]

Because there are many potential steps in the care transition, focusing on only 1 of these steps, such as medication reconciliation, is unlikely to have significant benefit on risk of readmission.[15] The pathways to readmission vary, as suggested both by the inability to accurately anticipate which patients will be readmitted,[28] and by case review studies characterizing underlying factors contributing to preventable readmissions.[29]

The problems with recommending that a specific intervention be broadly implemented include both the lack of evidence supporting such a recommendation and the likelihood that the transitional care gaps are not the same in all settings, or for all populations of patients treated. As health systems rapidly evolve, it may be useful for them to inventory strengths and weaknesses of their current approach to transitional care both to identify critical care gaps and to avoid investment in resource‐intensive transitional care interventions that may be redundant with existing activities.

Indeed, transitional care gaps may have changed over the last decade. Two large reviews showed that more recently published studies were less likely to have found an improvement in outcomes.[14, 24] In the years since some of the most successful and widely cited transitional care interventions were developed and evaluated, many health systems have undertaken major transformations, including the adoption of the patient‐centered medical home model and integration of electronic health records, which may implicitly address some earlier gaps. For instance, foundational qualitative work for the Care Transitions Measure identified discontinuities in information transfer as 1 of 4 major transitional care barriers identified by patients, and the personal health record was created, in part, to address this gap.[30] A shared electronic health record across healthcare settings has the potential to mitigate some of these concerns.

In general, there is an overarching need for better evidence to guide selection and implementation of complex, multicomponent transitional care interventions in different settings. There remain a number of gaps regarding the operationalization of interventions. For instance, the optimal choice of personnel, the comparative effects of home visits and other forms of postdischarge follow‐up, and the best approach to patient selection (whether through use of a formal readmission risk assessment model or a focus on populations with high‐risk comorbidities) are unknown.

One of the major weaknesses of the transitional care literature is the marked variation in intervention definitions, timing of outcome follow‐up, and descriptions of interventions and usual care. Use of taxonomies to guide study design and description may help standardize reporting.

Most of the care transitions literature has been hospital‐focused, and the interventions often extend hospital services beyond hospitalization. Given the growth of medical homes, it will be important to examine the effectiveness of outpatient‐based care transitions models that reach‐in to the hospital. Studies comparing approaches such as home‐visit and telephone‐based interventions, different risk‐prioritization schemes, and the use of different types of personnel are also needed.

There is very little literature examining transitional care interventions in patients with mental health conditions or undergoing surgery. A recent report for the Veterans Health Administration found that 24% of patients with chronic mental health conditions are readmitted within 30 days of discharge.[31] About 1 in 7 Medicare patients admitted to a surgical service is readmitted within 30 days.[32] The transitional care needs of these populations may differ substantially from medical populations and warrant further study.

Our review has a number of important limitations. Our overview of the literature was necessarily broad rather than in‐depth. There are many nuances in the results, internal validity, and generalizability of studies that are not represented in our overview. It was difficult to use established criteria to formally rate the strength of evidence for each of our conclusions, but we indicated strength of evidence ratings when reported in reviews. As we note in the results, our assessment of cross‐cutting themes is based largely on low‐strength evidence, given the indirect comparisons and the many factors that varied among the included studies. Our inclusion criteria specified readmissions as an outcome, but there are care transitions that focus exclusively on other outcomes, such as smoking cessation interventions around the time of discharge.[33] Furthermore, there are many outpatient‐based interventions designed to affect emergency room and hospital utilization that are not captured in our review, but may nevertheless be important to understanding the role of care coordination in the context of the medical home. We did not systematically update the included reviews' searches, and there may be more recent studies not represented here, though we are not aware of newer studies that would substantively change our summary of findings.

CONCLUSIONS

The literature includes many different types of interventions, studied in varied populations and clinical settings, and implemented in different ways. Furthermore, there are very little comparative effectiveness data. It is therefore difficult to conclusively identify specific intervention components and characteristics that are necessary for successful care transitions. Effective interventions are generally more comprehensive, address more aspects of the care transition, extend beyond the hospital stay, and have the flexibility to respond to individual patient needs. Transitional care interventions have not been well studied in integrated health system settings, or in mental health and surgical populations.

Disclosures: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the US government.

The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration (VHA) Project ESP 05‐225, VA#01‐0206. Dr. Jencks' work on this project was supported in part by a grant from the Quality Enhancement Research Initiative (05‐225), Department of Veterans Affairs. Dr. Jencks has reported prior consulting work with the following entities: Inovalon, Care Centrix, Affymax, Curaspan, Reinforced Care, Health Services Advisory Group, Delmarva Foundation, Connecticut Peer Review Organization, Maryland Health Services Cost Review Commission, Institute for Healthcare Improvement, American Association for Respiratory Care, Monaghan Medical, Iowa Society for Respiratory Care.

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.[1] Early studies showed that nurse‐led transitional care interventions beginning in the hospital and continuing after discharge had the potential to reduce the rate of hospital readmissions.[2, 3] Since then, the healthcare landscape has been evolving in important ways, with the spread of the electronic medical record, the patient‐centered medical home, and an increased push to health systems integration.[4, 5, 6]

The potential success or failure of transitional care interventions, which are inherently complex and can involve multiple components, may depend on the nature of the interventions themselves, the settings in which they were implemented, and/or the populations included. Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply.

The main aim of this article, culled from a larger report commissioned by the Veterans Health Administration (VHA)[7] was to catalogue which types of transitional care interventions hold promise and which populations have been best studied, to help health systems guide prioritization and adaptation of the most relevant transitional care activities and help focus future research efforts.

METHODS

We conducted a review of systematic reviews published in English, following Preferred Reporting Items for Systematic Reviews and Meta‐analyses reporting guideline for systematic reviews.[8] A protocol describing the review plan was posted to a public website before the study was initiated.[9] From an initial review of the literature, we recognized that most systematic reviews typically either examined different transitional care intervention types in a given patient population, or examined a given intervention type in a variety of patient populations. We use the term intervention type to refer to single‐ or multicomponent interventions that used a similar approach or bundle of care processes (eg, telemonitoring, hospital‐at‐home), or addressed a similar key process of the care transition (eg, medication reconciliation). Patient populations are defined according to clinical condition (eg, congestive heart failure) or demographic characteristics (eg, geriatric). Given that the review was originally commissioned by the VHA, we excluded pediatric and obstetric patient populations.

We identified categories of patient populations and intervention types with input from a panel of content experts, an initial scan of the literature, and with input from our study team to help guide our literature search (see Supporting Information, Appendix A, in the online version of this article). We searched PubMed and Cochrane databases of systematic reviews from database inception through May 2014.

We selected reviews that reported hospital readmissions as an outcome, regardless of whether it was the primary outcome. However, we summarized other outcomes reported by each review. Within each patient population or intervention type of interest, we first identified reviews that fulfilled key quality criteria: (1) clearly reported their search strategy, (2) reported inclusion and exclusion criteria, and (3) conducted an appraisal of the internal validity of the included trials.[10, 11] If there was more than 1 review within each category fulfilling these criteria, we prioritized the most recent review and those with the broadest scope. We discussed the ultimate choice of review as a group and resolved any disagreements through consensus. One author abstracted prespecified data from each review and a second author checked entries for accuracy (see Supporting Information, Appendix B, in the online version of this article).

We qualitatively synthesized the literature, using the categories of intervention type, patient population, and healthcare setting to organize our synthesis. We further identified common themes that cut across different intervention types and patient populations related to the following characteristics (derived from an existing taxonomy):[12] transition type (hospital to home, hospital to nursing facility), intervention target (patient, caregiver), key processes (education, personal health record), key personnel involved (nurse, social worker), method of postdischarge follow‐up (phone, home visits), and intensity and complexity. We developed brief narrative summaries of findings for each review. These narratives were compiled into a single document and reviewed independently by each of the authors of this report, who then compiled a brief list of key cross‐cutting themes in the evidence.

RESULTS

We reviewed 807 titles and abstracts from the electronic search, and identified an additional 94 from reviewing reference lists and performing manual searches for recently published and unpublished or ongoing studies (Figure 1). Eighty‐one systematic reviews met our inclusion criteria and, of these, we selected 17 that were the most recent and broadly scoped: 10 of intervention types (Table 1) and 7 of patient populations (Table 2).

Figure 1

DISCUSSION

We examined 17 systematic reviews across different patient populations representing a variety of intervention types to provide a broad overview of the care transitions literature. Variations in population studied, intervention definition, personnel, outcome definition, and setting make it difficult to identify strong evidence in support of a specific intervention type that should be broadly implemented. There were, however, some common themes that emerged across the literature suggesting that successful interventions addressed more aspects of the care transition, included the means to assess and respond to individual peridischarge needs, and included components that spanned care settings. In practical terms, the actualization of these themes has been accomplished in many interventions with the addition of transitional care personnel such as nurses and/or pharmacists. Additionally, interventions have often been tailored to the needs of individual patients with the use of needs assessment and patient‐centered personalized health records.[1]

Because there are many potential steps in the care transition, focusing on only 1 of these steps, such as medication reconciliation, is unlikely to have significant benefit on risk of readmission.[15] The pathways to readmission vary, as suggested both by the inability to accurately anticipate which patients will be readmitted,[28] and by case review studies characterizing underlying factors contributing to preventable readmissions.[29]

The problems with recommending that a specific intervention be broadly implemented include both the lack of evidence supporting such a recommendation and the likelihood that the transitional care gaps are not the same in all settings, or for all populations of patients treated. As health systems rapidly evolve, it may be useful for them to inventory strengths and weaknesses of their current approach to transitional care both to identify critical care gaps and to avoid investment in resource‐intensive transitional care interventions that may be redundant with existing activities.

Indeed, transitional care gaps may have changed over the last decade. Two large reviews showed that more recently published studies were less likely to have found an improvement in outcomes.[14, 24] In the years since some of the most successful and widely cited transitional care interventions were developed and evaluated, many health systems have undertaken major transformations, including the adoption of the patient‐centered medical home model and integration of electronic health records, which may implicitly address some earlier gaps. For instance, foundational qualitative work for the Care Transitions Measure identified discontinuities in information transfer as 1 of 4 major transitional care barriers identified by patients, and the personal health record was created, in part, to address this gap.[30] A shared electronic health record across healthcare settings has the potential to mitigate some of these concerns.

In general, there is an overarching need for better evidence to guide selection and implementation of complex, multicomponent transitional care interventions in different settings. There remain a number of gaps regarding the operationalization of interventions. For instance, the optimal choice of personnel, the comparative effects of home visits and other forms of postdischarge follow‐up, and the best approach to patient selection (whether through use of a formal readmission risk assessment model or a focus on populations with high‐risk comorbidities) are unknown.

One of the major weaknesses of the transitional care literature is the marked variation in intervention definitions, timing of outcome follow‐up, and descriptions of interventions and usual care. Use of taxonomies to guide study design and description may help standardize reporting.

Most of the care transitions literature has been hospital‐focused, and the interventions often extend hospital services beyond hospitalization. Given the growth of medical homes, it will be important to examine the effectiveness of outpatient‐based care transitions models that reach‐in to the hospital. Studies comparing approaches such as home‐visit and telephone‐based interventions, different risk‐prioritization schemes, and the use of different types of personnel are also needed.

There is very little literature examining transitional care interventions in patients with mental health conditions or undergoing surgery. A recent report for the Veterans Health Administration found that 24% of patients with chronic mental health conditions are readmitted within 30 days of discharge.[31] About 1 in 7 Medicare patients admitted to a surgical service is readmitted within 30 days.[32] The transitional care needs of these populations may differ substantially from medical populations and warrant further study.

Our review has a number of important limitations. Our overview of the literature was necessarily broad rather than in‐depth. There are many nuances in the results, internal validity, and generalizability of studies that are not represented in our overview. It was difficult to use established criteria to formally rate the strength of evidence for each of our conclusions, but we indicated strength of evidence ratings when reported in reviews. As we note in the results, our assessment of cross‐cutting themes is based largely on low‐strength evidence, given the indirect comparisons and the many factors that varied among the included studies. Our inclusion criteria specified readmissions as an outcome, but there are care transitions that focus exclusively on other outcomes, such as smoking cessation interventions around the time of discharge.[33] Furthermore, there are many outpatient‐based interventions designed to affect emergency room and hospital utilization that are not captured in our review, but may nevertheless be important to understanding the role of care coordination in the context of the medical home. We did not systematically update the included reviews' searches, and there may be more recent studies not represented here, though we are not aware of newer studies that would substantively change our summary of findings.

CONCLUSIONS

The literature includes many different types of interventions, studied in varied populations and clinical settings, and implemented in different ways. Furthermore, there are very little comparative effectiveness data. It is therefore difficult to conclusively identify specific intervention components and characteristics that are necessary for successful care transitions. Effective interventions are generally more comprehensive, address more aspects of the care transition, extend beyond the hospital stay, and have the flexibility to respond to individual patient needs. Transitional care interventions have not been well studied in integrated health system settings, or in mental health and surgical populations.

Disclosures: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the US government.

The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration (VHA) Project ESP 05‐225, VA#01‐0206. Dr. Jencks' work on this project was supported in part by a grant from the Quality Enhancement Research Initiative (05‐225), Department of Veterans Affairs. Dr. Jencks has reported prior consulting work with the following entities: Inovalon, Care Centrix, Affymax, Curaspan, Reinforced Care, Health Services Advisory Group, Delmarva Foundation, Connecticut Peer Review Organization, Maryland Health Services Cost Review Commission, Institute for Healthcare Improvement, American Association for Respiratory Care, Monaghan Medical, Iowa Society for Respiratory Care.

Hospital readmissions are common and costly, and represent a significant burden to the healthcare system. The challenges of postdischarge medication uncertainty, lack of self‐management support, and lack of timely access to health professionals1 are compounded in uninsured and Medicaid individuals by limited access to medications and primary care, financial strain, insecure housing, and limited social support.2

Our hospital cares for a large number of uninsured and low‐income publicly insured patients. The Portland area safety‐net, which consists of a network of 14 federally qualified health centers and free clinics, has limited capacity for uncompensated care. Uninsured patientsand to a lesser degree, Medicaid patientshave difficulty establishing primary care. Prior to the implementation of our program, uninsured and Medicaid patients without a usual source of care were given a list of safety‐net clinics at discharge, but frequently could not access appointments or navigate the complex system. There were no well‐developed partnerships between hospital and outpatient clinics for uninsured or Medicaid patients. The hospital lacked a systematic approach to securing postdischarge follow‐up and peridischarge patient education, and uninsured patients were financially responsible for most medications upon discharge. The costs of uncompensated or undercompensated potentially preventable readmissions for these patients, along with the recognition of gaps in quality, ultimately provided the rationale for a medical center‐funded transitional care intervention for uninsured and low‐income publicly insured patients.

Several transitional care improvement programs have shown effectiveness in reducing hospital readmissions,1, 35 but most have been conducted in settings where patients have secure access to outpatient care, and none have focused specifically on uninsured or Medicaid patients. Moreover, the development of these programs requires time and capital. Transitional care programs that have published results, to date, have been funded through government or private foundation grants1, 35; however, broader implementation of transitional care innovations will require financial and intellectual engagement of healthcare institutions themselves.

This report describes development of the Care Transitions Innovation (C‐TraIn), a multicomponent transitional care intervention for uninsured and low‐income publicly insured adults at a large, urban academic medical center, Oregon Health & Science University (OHSU). Because institutional funding and engagement is critical to the sustainability and scalability of similar programs, we also describe our process for gaining institutional support. Our hypothesis is that C‐TraIn can reduce readmissions and emergency department (ED) use at 30 days after hospital discharge, compared with usual care.

METHODS

PROGRAM EVALUATION

We are conducting a clustered, randomized controlled trial to evaluate C‐TraIn's impact on quality, access, and high‐cost utilization at 30 days after hospital discharge. Results are anticipated in mid‐2012. We chose to perform an analysis clustered by admitting team, because communication between the C‐TraIn nurse, physician team, and pharmacist consult services could introduce secular change effects that could impact the care received by other patients on a given team. There are 5 general medicine resident teams, 1 hospitalist service, and 1 cardiology service, and the physician personnel for each team changes from month to month. Because the cardiology and hospitalist services differ slightly from resident teams, we chose a randomized cross‐over design such that intervention and control teams are redesignated every 3 months. To enhance internal validity, study personnel who enroll patients and administer baseline and 30‐day surveys are blinded to intervention status. We are collecting data on prior utilization, usual source of care, outpatient access, insurance, patient activation,6 functional status,7, 8 self‐rated health,7 health literacy, care transitions education,9 alcohol and substance abuse, and social support.10 Our primary outcome will be self‐reported 30‐day hospital readmission and ED use. We will also evaluate administrative claims data to identify 30‐day OHSU readmission and ED utilization rates. We will assess whether improved access to medications, rates of outpatient follow‐up and time to follow‐up mediate any effect on primary outcomes. Secondary outcomes will include outpatient utilization, patient activation, self‐rated health, and functional status.

Given limited experience with transitional care programs in socioeconomically disadvantaged patients, we are measuring acceptability and feasibility by tracking rates of those declining the intervention, and through semi‐structured interviews at 30 days. We are monitoring fidelity to core elements of the program through chart and checklist reviews, and seeking provider feedback through in‐person meetings with key implementers. To ensure possibility of broader adoption beyond OHSU, we are developing a toolkit that defines core program elements and can be adapted for use in various settings.

DISCUSSION

Using a process of broad stakeholder engagement, exposure of financial incentives, and data‐driven understanding of institutional and population needs, we built consensus and gained institutional financial commitment for implementation of a multicomponent transitional care program for uninsured and Medicaid patients. Our experience is relevant to other hospital systems, and may have particular relevance to academic medical centers, whose tripartite mission of clinical care, research, and education make them a natural place for healthcare reform.11

Several key lessons from our experience may be widely applicable. First, key administrative allies helped us understand institutional priorities and identify key institutional change‐agents. Though initial attempts to gain support were met cautiously, persistent advocacy, development of a strong business case, and support from several administrative allies compelled further leadership support. Second, unlike traditional grant funding cycles, hospital budgets operate in real‐time rapid‐change cycles, necessitating rapid data collection, analysis, and program design. Such demands could potentially threaten the viability of the program itself, or result in premature diffusion of novel practices into disparate populations. Communication with administrative leadership about the value of sound research design within the context of faster‐paced institutional needs was important and allowed time for data‐driven program development and diffusion. Simultaneously, we recognized the need to move quickly, provide regular progress updates, and use existing institutional resources, such as volunteer students and business development office, when possible.

We found that cross‐site hospitalcommunity partnerships are an essential program element. Partnership occurs through a payment agreement and through active engagement in ongoing quality improvement, including clinic representation at monthly team meetings. Clinic partnerships have enabled multidisciplinary cross‐site communication and relationships that facilitate innovation across routinely siloed elements of the system, allowing the team to anticipate and respond to patient problems before they lead to readmissions or poor outcomes. Our experience matches findings from recent program evaluations that found that care coordination attempts are unsuccessful without strong cross‐site linkages.12 These linkages are especially challenging and needed for uninsured and Medicaid patients, given their traditional lack of access and the additional social and financial barriers that influence their care.13

Limitations of our study include: implementation at a single, academic medical center; secular changes (which we mitigate against using randomized trial design); and potential for low power, if readmission rates are lower than anticipated from needs assessment data. Additionally, the need for a willing and invested program champion to coordinate an often messy, complex intervention may limit generalizability.

While transitional care programs continue to proliferate in response to increasingly recognized gaps in a fragmented care system,14, 15 few interventions specifically address the needs of socioeconomically disadvantaged patients. The major study that did5 was conducted in Massachusetts, where many patients received care through a state Free Care program and robust local safety‐net. Others have largely been tested in integrated care settings,1 and target patients who are part of managed care programs.1, 4, 16

To our knowledge, there are no well‐described programs that include explicit purchasing of outpatient medical homes for uninsured patients who would not otherwise have access to care. Our experience shifts the paradigm of the role of hospitals in care for the uninsured and underinsured: instead of a reactive, uncoordinated role, we assert that the hospital's strategic up‐front allocation of resources has a sound business, quality, and ethical foundation. This is especially important, given a new era of payment reform and coordinated care organizations. There is an opportunity to both improve quality for the uninsured and Medicaid patients, control costs, and gain valuable experience that can inform transitional care improvements for broader patient populations. If our study is successful in reducing readmissions, there may be important implications as to how to redefine the hospital's role in outpatient access to care linkages, especially for uninsured and Medicaid patients.

Hospital readmissions are common and costly, and represent a significant burden to the healthcare system. The challenges of postdischarge medication uncertainty, lack of self‐management support, and lack of timely access to health professionals1 are compounded in uninsured and Medicaid individuals by limited access to medications and primary care, financial strain, insecure housing, and limited social support.2

Our hospital cares for a large number of uninsured and low‐income publicly insured patients. The Portland area safety‐net, which consists of a network of 14 federally qualified health centers and free clinics, has limited capacity for uncompensated care. Uninsured patientsand to a lesser degree, Medicaid patientshave difficulty establishing primary care. Prior to the implementation of our program, uninsured and Medicaid patients without a usual source of care were given a list of safety‐net clinics at discharge, but frequently could not access appointments or navigate the complex system. There were no well‐developed partnerships between hospital and outpatient clinics for uninsured or Medicaid patients. The hospital lacked a systematic approach to securing postdischarge follow‐up and peridischarge patient education, and uninsured patients were financially responsible for most medications upon discharge. The costs of uncompensated or undercompensated potentially preventable readmissions for these patients, along with the recognition of gaps in quality, ultimately provided the rationale for a medical center‐funded transitional care intervention for uninsured and low‐income publicly insured patients.

Several transitional care improvement programs have shown effectiveness in reducing hospital readmissions,1, 35 but most have been conducted in settings where patients have secure access to outpatient care, and none have focused specifically on uninsured or Medicaid patients. Moreover, the development of these programs requires time and capital. Transitional care programs that have published results, to date, have been funded through government or private foundation grants1, 35; however, broader implementation of transitional care innovations will require financial and intellectual engagement of healthcare institutions themselves.

This report describes development of the Care Transitions Innovation (C‐TraIn), a multicomponent transitional care intervention for uninsured and low‐income publicly insured adults at a large, urban academic medical center, Oregon Health & Science University (OHSU). Because institutional funding and engagement is critical to the sustainability and scalability of similar programs, we also describe our process for gaining institutional support. Our hypothesis is that C‐TraIn can reduce readmissions and emergency department (ED) use at 30 days after hospital discharge, compared with usual care.

METHODS

PROGRAM EVALUATION

We are conducting a clustered, randomized controlled trial to evaluate C‐TraIn's impact on quality, access, and high‐cost utilization at 30 days after hospital discharge. Results are anticipated in mid‐2012. We chose to perform an analysis clustered by admitting team, because communication between the C‐TraIn nurse, physician team, and pharmacist consult services could introduce secular change effects that could impact the care received by other patients on a given team. There are 5 general medicine resident teams, 1 hospitalist service, and 1 cardiology service, and the physician personnel for each team changes from month to month. Because the cardiology and hospitalist services differ slightly from resident teams, we chose a randomized cross‐over design such that intervention and control teams are redesignated every 3 months. To enhance internal validity, study personnel who enroll patients and administer baseline and 30‐day surveys are blinded to intervention status. We are collecting data on prior utilization, usual source of care, outpatient access, insurance, patient activation,6 functional status,7, 8 self‐rated health,7 health literacy, care transitions education,9 alcohol and substance abuse, and social support.10 Our primary outcome will be self‐reported 30‐day hospital readmission and ED use. We will also evaluate administrative claims data to identify 30‐day OHSU readmission and ED utilization rates. We will assess whether improved access to medications, rates of outpatient follow‐up and time to follow‐up mediate any effect on primary outcomes. Secondary outcomes will include outpatient utilization, patient activation, self‐rated health, and functional status.

Given limited experience with transitional care programs in socioeconomically disadvantaged patients, we are measuring acceptability and feasibility by tracking rates of those declining the intervention, and through semi‐structured interviews at 30 days. We are monitoring fidelity to core elements of the program through chart and checklist reviews, and seeking provider feedback through in‐person meetings with key implementers. To ensure possibility of broader adoption beyond OHSU, we are developing a toolkit that defines core program elements and can be adapted for use in various settings.

DISCUSSION

Using a process of broad stakeholder engagement, exposure of financial incentives, and data‐driven understanding of institutional and population needs, we built consensus and gained institutional financial commitment for implementation of a multicomponent transitional care program for uninsured and Medicaid patients. Our experience is relevant to other hospital systems, and may have particular relevance to academic medical centers, whose tripartite mission of clinical care, research, and education make them a natural place for healthcare reform.11

Several key lessons from our experience may be widely applicable. First, key administrative allies helped us understand institutional priorities and identify key institutional change‐agents. Though initial attempts to gain support were met cautiously, persistent advocacy, development of a strong business case, and support from several administrative allies compelled further leadership support. Second, unlike traditional grant funding cycles, hospital budgets operate in real‐time rapid‐change cycles, necessitating rapid data collection, analysis, and program design. Such demands could potentially threaten the viability of the program itself, or result in premature diffusion of novel practices into disparate populations. Communication with administrative leadership about the value of sound research design within the context of faster‐paced institutional needs was important and allowed time for data‐driven program development and diffusion. Simultaneously, we recognized the need to move quickly, provide regular progress updates, and use existing institutional resources, such as volunteer students and business development office, when possible.

We found that cross‐site hospitalcommunity partnerships are an essential program element. Partnership occurs through a payment agreement and through active engagement in ongoing quality improvement, including clinic representation at monthly team meetings. Clinic partnerships have enabled multidisciplinary cross‐site communication and relationships that facilitate innovation across routinely siloed elements of the system, allowing the team to anticipate and respond to patient problems before they lead to readmissions or poor outcomes. Our experience matches findings from recent program evaluations that found that care coordination attempts are unsuccessful without strong cross‐site linkages.12 These linkages are especially challenging and needed for uninsured and Medicaid patients, given their traditional lack of access and the additional social and financial barriers that influence their care.13

Limitations of our study include: implementation at a single, academic medical center; secular changes (which we mitigate against using randomized trial design); and potential for low power, if readmission rates are lower than anticipated from needs assessment data. Additionally, the need for a willing and invested program champion to coordinate an often messy, complex intervention may limit generalizability.

While transitional care programs continue to proliferate in response to increasingly recognized gaps in a fragmented care system,14, 15 few interventions specifically address the needs of socioeconomically disadvantaged patients. The major study that did5 was conducted in Massachusetts, where many patients received care through a state Free Care program and robust local safety‐net. Others have largely been tested in integrated care settings,1 and target patients who are part of managed care programs.1, 4, 16

To our knowledge, there are no well‐described programs that include explicit purchasing of outpatient medical homes for uninsured patients who would not otherwise have access to care. Our experience shifts the paradigm of the role of hospitals in care for the uninsured and underinsured: instead of a reactive, uncoordinated role, we assert that the hospital's strategic up‐front allocation of resources has a sound business, quality, and ethical foundation. This is especially important, given a new era of payment reform and coordinated care organizations. There is an opportunity to both improve quality for the uninsured and Medicaid patients, control costs, and gain valuable experience that can inform transitional care improvements for broader patient populations. If our study is successful in reducing readmissions, there may be important implications as to how to redefine the hospital's role in outpatient access to care linkages, especially for uninsured and Medicaid patients.

Hospital readmissions are common and costly, and represent a significant burden to the healthcare system. The challenges of postdischarge medication uncertainty, lack of self‐management support, and lack of timely access to health professionals1 are compounded in uninsured and Medicaid individuals by limited access to medications and primary care, financial strain, insecure housing, and limited social support.2

Our hospital cares for a large number of uninsured and low‐income publicly insured patients. The Portland area safety‐net, which consists of a network of 14 federally qualified health centers and free clinics, has limited capacity for uncompensated care. Uninsured patientsand to a lesser degree, Medicaid patientshave difficulty establishing primary care. Prior to the implementation of our program, uninsured and Medicaid patients without a usual source of care were given a list of safety‐net clinics at discharge, but frequently could not access appointments or navigate the complex system. There were no well‐developed partnerships between hospital and outpatient clinics for uninsured or Medicaid patients. The hospital lacked a systematic approach to securing postdischarge follow‐up and peridischarge patient education, and uninsured patients were financially responsible for most medications upon discharge. The costs of uncompensated or undercompensated potentially preventable readmissions for these patients, along with the recognition of gaps in quality, ultimately provided the rationale for a medical center‐funded transitional care intervention for uninsured and low‐income publicly insured patients.

Several transitional care improvement programs have shown effectiveness in reducing hospital readmissions,1, 35 but most have been conducted in settings where patients have secure access to outpatient care, and none have focused specifically on uninsured or Medicaid patients. Moreover, the development of these programs requires time and capital. Transitional care programs that have published results, to date, have been funded through government or private foundation grants1, 35; however, broader implementation of transitional care innovations will require financial and intellectual engagement of healthcare institutions themselves.

This report describes development of the Care Transitions Innovation (C‐TraIn), a multicomponent transitional care intervention for uninsured and low‐income publicly insured adults at a large, urban academic medical center, Oregon Health & Science University (OHSU). Because institutional funding and engagement is critical to the sustainability and scalability of similar programs, we also describe our process for gaining institutional support. Our hypothesis is that C‐TraIn can reduce readmissions and emergency department (ED) use at 30 days after hospital discharge, compared with usual care.

METHODS

PROGRAM EVALUATION

We are conducting a clustered, randomized controlled trial to evaluate C‐TraIn's impact on quality, access, and high‐cost utilization at 30 days after hospital discharge. Results are anticipated in mid‐2012. We chose to perform an analysis clustered by admitting team, because communication between the C‐TraIn nurse, physician team, and pharmacist consult services could introduce secular change effects that could impact the care received by other patients on a given team. There are 5 general medicine resident teams, 1 hospitalist service, and 1 cardiology service, and the physician personnel for each team changes from month to month. Because the cardiology and hospitalist services differ slightly from resident teams, we chose a randomized cross‐over design such that intervention and control teams are redesignated every 3 months. To enhance internal validity, study personnel who enroll patients and administer baseline and 30‐day surveys are blinded to intervention status. We are collecting data on prior utilization, usual source of care, outpatient access, insurance, patient activation,6 functional status,7, 8 self‐rated health,7 health literacy, care transitions education,9 alcohol and substance abuse, and social support.10 Our primary outcome will be self‐reported 30‐day hospital readmission and ED use. We will also evaluate administrative claims data to identify 30‐day OHSU readmission and ED utilization rates. We will assess whether improved access to medications, rates of outpatient follow‐up and time to follow‐up mediate any effect on primary outcomes. Secondary outcomes will include outpatient utilization, patient activation, self‐rated health, and functional status.

Given limited experience with transitional care programs in socioeconomically disadvantaged patients, we are measuring acceptability and feasibility by tracking rates of those declining the intervention, and through semi‐structured interviews at 30 days. We are monitoring fidelity to core elements of the program through chart and checklist reviews, and seeking provider feedback through in‐person meetings with key implementers. To ensure possibility of broader adoption beyond OHSU, we are developing a toolkit that defines core program elements and can be adapted for use in various settings.

DISCUSSION

Using a process of broad stakeholder engagement, exposure of financial incentives, and data‐driven understanding of institutional and population needs, we built consensus and gained institutional financial commitment for implementation of a multicomponent transitional care program for uninsured and Medicaid patients. Our experience is relevant to other hospital systems, and may have particular relevance to academic medical centers, whose tripartite mission of clinical care, research, and education make them a natural place for healthcare reform.11

Several key lessons from our experience may be widely applicable. First, key administrative allies helped us understand institutional priorities and identify key institutional change‐agents. Though initial attempts to gain support were met cautiously, persistent advocacy, development of a strong business case, and support from several administrative allies compelled further leadership support. Second, unlike traditional grant funding cycles, hospital budgets operate in real‐time rapid‐change cycles, necessitating rapid data collection, analysis, and program design. Such demands could potentially threaten the viability of the program itself, or result in premature diffusion of novel practices into disparate populations. Communication with administrative leadership about the value of sound research design within the context of faster‐paced institutional needs was important and allowed time for data‐driven program development and diffusion. Simultaneously, we recognized the need to move quickly, provide regular progress updates, and use existing institutional resources, such as volunteer students and business development office, when possible.

We found that cross‐site hospitalcommunity partnerships are an essential program element. Partnership occurs through a payment agreement and through active engagement in ongoing quality improvement, including clinic representation at monthly team meetings. Clinic partnerships have enabled multidisciplinary cross‐site communication and relationships that facilitate innovation across routinely siloed elements of the system, allowing the team to anticipate and respond to patient problems before they lead to readmissions or poor outcomes. Our experience matches findings from recent program evaluations that found that care coordination attempts are unsuccessful without strong cross‐site linkages.12 These linkages are especially challenging and needed for uninsured and Medicaid patients, given their traditional lack of access and the additional social and financial barriers that influence their care.13

Limitations of our study include: implementation at a single, academic medical center; secular changes (which we mitigate against using randomized trial design); and potential for low power, if readmission rates are lower than anticipated from needs assessment data. Additionally, the need for a willing and invested program champion to coordinate an often messy, complex intervention may limit generalizability.

While transitional care programs continue to proliferate in response to increasingly recognized gaps in a fragmented care system,14, 15 few interventions specifically address the needs of socioeconomically disadvantaged patients. The major study that did5 was conducted in Massachusetts, where many patients received care through a state Free Care program and robust local safety‐net. Others have largely been tested in integrated care settings,1 and target patients who are part of managed care programs.1, 4, 16

To our knowledge, there are no well‐described programs that include explicit purchasing of outpatient medical homes for uninsured patients who would not otherwise have access to care. Our experience shifts the paradigm of the role of hospitals in care for the uninsured and underinsured: instead of a reactive, uncoordinated role, we assert that the hospital's strategic up‐front allocation of resources has a sound business, quality, and ethical foundation. This is especially important, given a new era of payment reform and coordinated care organizations. There is an opportunity to both improve quality for the uninsured and Medicaid patients, control costs, and gain valuable experience that can inform transitional care improvements for broader patient populations. If our study is successful in reducing readmissions, there may be important implications as to how to redefine the hospital's role in outpatient access to care linkages, especially for uninsured and Medicaid patients.

The inpatient to outpatient transition marks an abrupt paradigm shift from intensive, provider‐initiated care to self‐managed care, in which patients are primarily responsible for maintaining day‐to‐day health behaviors, following through with outpatient appointments, and negotiating medications, transport, and equipment needs. Studies indicate that medication nonadherence and medication‐related adverse events are common during the post‐discharge period, and may be related to the discontinuities associated with transitions of care.110

Given the complexity and uncertainty inherent in care transitions for patients with chronic illness, it is not surprising that poorly executed care transitions have been associated with increased risk of rehospitalizations and emergency department (ED) use.11 Patients with chronic illness are at particularly high risk for recurrent hospitalization.1114 System‐wide improvements in chronic illness care have been successful in triaging longitudinally followed, high‐risk outpatients to appropriate higher‐intensity care management interventions.1519 But the post‐discharge setting presents unique challenges for patients with chronic illness, especially those that are socioeconomically disadvantaged. External barriers, such as lack of transportation, lack of monitoring equipment, confusion about arranging follow‐up care, uncertainty about medication regimen changes, and financial constraints, represent important targets for improving care in the transition from inpatient to outpatient settings.

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as members transfer between different locations or different levels of care.20 Most successful transitional care interventions have focused on geriatric populations or patients with congestive heart failure enrolled in health maintenance organizations, and have involved intensive nurse case management from the hospital setting through the post‐discharge period.2125 In these studies, trained nurse case managers provided critical support and patient education to improve patients' ability to self‐manage chronic illness.2629

In a resource‐poor Medicaid payment structure, the implementation of intensive care management across a broad population of patients may not be practical; alternative options for intervention dosing and implementation may be needed. Few studies have examined care needs and the impact of transitional care interventions in socioeconomically disadvantaged patients with chronic illness, though a recent study including such a population did find benefit from a pharmacist‐based intervention.30 The purpose of our study was to examine the impact of a low‐cost, post‐discharge needs assessment, as an adjunct to an existing care management program, on the risk of recurrent hospitalization in a clinically diverse cohort of chronically ill Medicaid managed care enrollees.

METHODS

RESULTS

We enrolled 97 intervention and 130 control patients. Follow‐up utilization data were available for all patients. Table 1 compares sociodemographic, utilization, and comorbidity characteristics of the 2 groups, and Table 2 summarizes patient distribution and characteristics of the hospitals from which they were discharged. The control group was significantly older and more racially diverse than the intervention group. On the other hand, the intervention group had a higher burden of illness as suggested by higher ACG scores and a higher rate of hospitalization within the previous year. Most patients had been hospitalized at large, urban hospitals.

Patients in the intervention group had a slightly lower 60‐day rehospitalization rate compared to the control group, but this difference was not statistically significant in unadjusted analyses (Table 3; 23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24‐1.00].

Nearly half the intervention patients received one or more brief‐touch interventions (48.5%), and the majority of patients (61.7%) receiving a brief‐touch intervention did not require referral to care management. Table 4 lists examples of brief‐touch interventions received by patients. More patients in the intervention group than in the control group were enrolled in the CareSupport care management program (40.2% vs 14.6%, P < 0.001), and about half (53.8%) of the intervention patients referred for care management did not receive a brief‐touch intervention. Patients enrolled in care management were slightly younger (mean age 56.7 vs 59.1 years, P = 0.16), but had a higher burden of illness (mean ACG score 0.53 vs 0.40, P = 0.006) than those not enrolled in care management.

More patients in the intervention group compared to control patients had one or more primary care visits within the year after hospital discharge (86.6% vs 72.3%, P = 0.01), and within 60 days after hospital discharge (68.0% vs 58.5%, P = 0.14), though the latter difference did not reach statistical significance. Interestingly, in an exploratory analysis, we found that hospitalization was more likely to introduce discontinuities in longitudinal primary care in control patients than in intervention patients: among patients who had had 3 or more primary care visits in the year prior to hospitalization, control patients were more likely than intervention patients to have 2 or fewer primary care visits during the year following hospitalization (33.8% vs 20.6%, P = 0.03).

Our mediation analyses suggested that neither post‐hospitalization primary care utilization within 60 days nor care management services accounted for the lower rate of recurrent hospitalization in the intervention group (Table 3). The addition of post‐hospitalization primary care utilization to the original model did not change the primary effect estimate, while controlling for care management enrollment actually increased the effect size. Finally, there was no difference in readmission rates between those receiving and not receiving brief‐touch interventions (31.8 vs 25.7%, P = 0.92).

DISCUSSION

We found that a simple, telephone‐based, transitional care intervention may be associated with lower 60‐day rehospitalization rates in a cohort of Medicaid managed care patients. We observed a reduced rate of readmissions in the intervention, a difference that became significant after adjustment for important confounders. Implicit in the design of the intervention was a recognition that patients' transitional care needs may vary, from help negotiating the post‐discharge follow‐up care process to more substantial and complex care management support needs. Our study adds to the current body of literature by examining an understudied, socioeconomically disadvantaged population in a resource‐poor health system. Importantly, our study targeted the most intensive intervention to those with the highest anticipated needs based on a simple triage scheme. Such targeted approaches may be especially important in resource‐poor settings.

Although our study was too small to characterize in detail the relative importance of specific elements of our intervention responsible for lower short‐term rehospitalization rates, the study does highlight the diversity of transitional care needs. Patients received logistic support negotiating the health system, preventive health promotion, and patient empowerment through self‐management and information access training. Nearly half the patients received a documented simple telephone‐based intervention, and many of these patients did not require referral for intensive nurse care management. On the other hand, our needs assessment did identify over one‐third of recently discharged patients as having more complex chronic disease management needs requiring assessment for ongoing nurse care management.

We were not able to identify the specific aspects of the intervention responsible for the observed reduction in recurrent hospitalization. Our mediation analysis suggests that triaging patients to a nurse care management program was not responsible for the observed reduction in recurrent hospitalizations. In fact, the analysis suggests these patients may have been more likely to require hospitalization, though our study was too small to allow strong conclusions to be drawn from a subgroup analysis. Past studies have similarly suggested that patients enrolled in care management may simply have a higher burden of disease or may have the need for hospitalization recognized more frequently.36 Readmission rates were also similar between patients who did and did not receive a brief‐touch intervention, possibly suggesting that patients with a higher level of need were appropriately selected to receive assistance.

Although our intervention appeared to increase post‐discharge follow‐up in primary care, this also did not explain the observed reduction in 60‐day rehospitalization rates. Despite differences in post‐discharge outpatient utilization patterns, there were relatively few patients in either group that had no follow‐up, and the lack of effect may simply reflect inadequate power given our small sample size. On the other hand, the lack of association between outpatient utilization and 60‐day rehospitalization rates may reflect a true lack of association between primary care follow‐up and rehospitalization as seen in some studies, though a larger Medicare study did find an association.3638

Improvements in outpatient utilization patterns, as we saw in this study, may be a laudable intermediate outcome benefit despite the lack of association with 60‐day rehospitalization rates in our study. Short‐term rehospitalization rates represent only one outcome and do not capture the expected slow, iterative benefits from chronic illness risk reduction, which may accrue over time, with stable longitudinal primary care and associated outpatient chronic illness care systems' innovations.15, 31, 39, 40

Recent studies of transitional care interventions in publicly insured adults have produced mixed results. An evaluation of Medicare demonstration projects found largely negative results, but did find 2 successful programs in which the highest‐risk patients seemed to benefit most, a finding that supports the importance of assessing risk and appropriately dosing interventions.41 Another recent study in a socioeconomically disadvantaged population suggests the utility of an alternate transitional care approach centered on a pharmacy‐based intervention.30

Ours is essentially a test‐of‐concept study, with several important limitations, which should temper widespread application of these results and suggest the need for further study. The sample size of our study was limited, and this, coupled with a slightly lower‐than‐expected event rate, limits our ability to detect potentially important effects. Our study was not a randomized trial, and we cannot discount the possibility that our results reflect the effect of residual or unmeasured confounders, especially those factors such as patient volume and care quality related to the discharging hospitals themselves. We attempted to minimize the effects of such confounders by balancing the types of hospitals included in each group, and by accounting for clustering by hospital in our statistical analysis. Important differences in baseline characteristics between the 2 groups also raise the possibility of residual confounding despite multivariate adjustment. However, the intervention group generally carried a higher burden of illness which would, if anything, have biased results towards the null. The pragmatic study design necessitated an intervention that was defined broadly and left much to the discretion of the staff delivering the intervention, rather than adherence to a strictly defined protocol. We believe this approach allows evaluation of systems innovations within limited‐resource settings, but we acknowledge the challenges this presents in applying study results to other settings. Finally, only approximately 1 in 4 intervention patients were successfully contacted and completed the post‐discharge survey within 1 week. The relatively low rate of successful telephone contact underscores the difficulty of implementing transitional care interventions dependent on post‐discharge contact in a socioeconomically disadvantaged population with unstable telephone access. Because only successfully contacted patients were included in the intervention group, selection bias is a potential issue, though again, most baseline discrepancies between the 2 groups suggest that intervention patients were more complex.

Transitions of care in uninsured and publicly insured nonelderly adults should be studied in greater depth. Outpatient access to care deficiencies may be compounded in these groups, especially as states face widespread budget crises. Future studies should examine the effects of inpatient to outpatient linkages for such patients. Also, studies should assess the impact of transitional care interventions on self‐management, quality of care, and intermediate health outcomes in the outpatient setting after hospital discharge. Future research should taxonomize the range of transitional care needs by qualitatively evaluating subgroups of patients and delineating challenges faced by each group. For example, the post‐discharge needs of marginally housed patients may be unique and could inform the development of interventions specifically targeted to this group.

In summary, we found that a simple, brief‐touch intervention and needs assessment in the post‐discharge period may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse post‐discharge care needs, though the exact mechanisms responsible for the observed improvements are unclear. Future studies should evaluate transitional care interventions targeted to needs in a larger group of chronically ill patients.

The inpatient to outpatient transition marks an abrupt paradigm shift from intensive, provider‐initiated care to self‐managed care, in which patients are primarily responsible for maintaining day‐to‐day health behaviors, following through with outpatient appointments, and negotiating medications, transport, and equipment needs. Studies indicate that medication nonadherence and medication‐related adverse events are common during the post‐discharge period, and may be related to the discontinuities associated with transitions of care.110

Given the complexity and uncertainty inherent in care transitions for patients with chronic illness, it is not surprising that poorly executed care transitions have been associated with increased risk of rehospitalizations and emergency department (ED) use.11 Patients with chronic illness are at particularly high risk for recurrent hospitalization.1114 System‐wide improvements in chronic illness care have been successful in triaging longitudinally followed, high‐risk outpatients to appropriate higher‐intensity care management interventions.1519 But the post‐discharge setting presents unique challenges for patients with chronic illness, especially those that are socioeconomically disadvantaged. External barriers, such as lack of transportation, lack of monitoring equipment, confusion about arranging follow‐up care, uncertainty about medication regimen changes, and financial constraints, represent important targets for improving care in the transition from inpatient to outpatient settings.

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as members transfer between different locations or different levels of care.20 Most successful transitional care interventions have focused on geriatric populations or patients with congestive heart failure enrolled in health maintenance organizations, and have involved intensive nurse case management from the hospital setting through the post‐discharge period.2125 In these studies, trained nurse case managers provided critical support and patient education to improve patients' ability to self‐manage chronic illness.2629

In a resource‐poor Medicaid payment structure, the implementation of intensive care management across a broad population of patients may not be practical; alternative options for intervention dosing and implementation may be needed. Few studies have examined care needs and the impact of transitional care interventions in socioeconomically disadvantaged patients with chronic illness, though a recent study including such a population did find benefit from a pharmacist‐based intervention.30 The purpose of our study was to examine the impact of a low‐cost, post‐discharge needs assessment, as an adjunct to an existing care management program, on the risk of recurrent hospitalization in a clinically diverse cohort of chronically ill Medicaid managed care enrollees.

METHODS

RESULTS

We enrolled 97 intervention and 130 control patients. Follow‐up utilization data were available for all patients. Table 1 compares sociodemographic, utilization, and comorbidity characteristics of the 2 groups, and Table 2 summarizes patient distribution and characteristics of the hospitals from which they were discharged. The control group was significantly older and more racially diverse than the intervention group. On the other hand, the intervention group had a higher burden of illness as suggested by higher ACG scores and a higher rate of hospitalization within the previous year. Most patients had been hospitalized at large, urban hospitals.

Patients in the intervention group had a slightly lower 60‐day rehospitalization rate compared to the control group, but this difference was not statistically significant in unadjusted analyses (Table 3; 23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24‐1.00].

Nearly half the intervention patients received one or more brief‐touch interventions (48.5%), and the majority of patients (61.7%) receiving a brief‐touch intervention did not require referral to care management. Table 4 lists examples of brief‐touch interventions received by patients. More patients in the intervention group than in the control group were enrolled in the CareSupport care management program (40.2% vs 14.6%, P < 0.001), and about half (53.8%) of the intervention patients referred for care management did not receive a brief‐touch intervention. Patients enrolled in care management were slightly younger (mean age 56.7 vs 59.1 years, P = 0.16), but had a higher burden of illness (mean ACG score 0.53 vs 0.40, P = 0.006) than those not enrolled in care management.

More patients in the intervention group compared to control patients had one or more primary care visits within the year after hospital discharge (86.6% vs 72.3%, P = 0.01), and within 60 days after hospital discharge (68.0% vs 58.5%, P = 0.14), though the latter difference did not reach statistical significance. Interestingly, in an exploratory analysis, we found that hospitalization was more likely to introduce discontinuities in longitudinal primary care in control patients than in intervention patients: among patients who had had 3 or more primary care visits in the year prior to hospitalization, control patients were more likely than intervention patients to have 2 or fewer primary care visits during the year following hospitalization (33.8% vs 20.6%, P = 0.03).

Our mediation analyses suggested that neither post‐hospitalization primary care utilization within 60 days nor care management services accounted for the lower rate of recurrent hospitalization in the intervention group (Table 3). The addition of post‐hospitalization primary care utilization to the original model did not change the primary effect estimate, while controlling for care management enrollment actually increased the effect size. Finally, there was no difference in readmission rates between those receiving and not receiving brief‐touch interventions (31.8 vs 25.7%, P = 0.92).

DISCUSSION

We found that a simple, telephone‐based, transitional care intervention may be associated with lower 60‐day rehospitalization rates in a cohort of Medicaid managed care patients. We observed a reduced rate of readmissions in the intervention, a difference that became significant after adjustment for important confounders. Implicit in the design of the intervention was a recognition that patients' transitional care needs may vary, from help negotiating the post‐discharge follow‐up care process to more substantial and complex care management support needs. Our study adds to the current body of literature by examining an understudied, socioeconomically disadvantaged population in a resource‐poor health system. Importantly, our study targeted the most intensive intervention to those with the highest anticipated needs based on a simple triage scheme. Such targeted approaches may be especially important in resource‐poor settings.

Although our study was too small to characterize in detail the relative importance of specific elements of our intervention responsible for lower short‐term rehospitalization rates, the study does highlight the diversity of transitional care needs. Patients received logistic support negotiating the health system, preventive health promotion, and patient empowerment through self‐management and information access training. Nearly half the patients received a documented simple telephone‐based intervention, and many of these patients did not require referral for intensive nurse care management. On the other hand, our needs assessment did identify over one‐third of recently discharged patients as having more complex chronic disease management needs requiring assessment for ongoing nurse care management.

We were not able to identify the specific aspects of the intervention responsible for the observed reduction in recurrent hospitalization. Our mediation analysis suggests that triaging patients to a nurse care management program was not responsible for the observed reduction in recurrent hospitalizations. In fact, the analysis suggests these patients may have been more likely to require hospitalization, though our study was too small to allow strong conclusions to be drawn from a subgroup analysis. Past studies have similarly suggested that patients enrolled in care management may simply have a higher burden of disease or may have the need for hospitalization recognized more frequently.36 Readmission rates were also similar between patients who did and did not receive a brief‐touch intervention, possibly suggesting that patients with a higher level of need were appropriately selected to receive assistance.

Although our intervention appeared to increase post‐discharge follow‐up in primary care, this also did not explain the observed reduction in 60‐day rehospitalization rates. Despite differences in post‐discharge outpatient utilization patterns, there were relatively few patients in either group that had no follow‐up, and the lack of effect may simply reflect inadequate power given our small sample size. On the other hand, the lack of association between outpatient utilization and 60‐day rehospitalization rates may reflect a true lack of association between primary care follow‐up and rehospitalization as seen in some studies, though a larger Medicare study did find an association.3638

Improvements in outpatient utilization patterns, as we saw in this study, may be a laudable intermediate outcome benefit despite the lack of association with 60‐day rehospitalization rates in our study. Short‐term rehospitalization rates represent only one outcome and do not capture the expected slow, iterative benefits from chronic illness risk reduction, which may accrue over time, with stable longitudinal primary care and associated outpatient chronic illness care systems' innovations.15, 31, 39, 40

Recent studies of transitional care interventions in publicly insured adults have produced mixed results. An evaluation of Medicare demonstration projects found largely negative results, but did find 2 successful programs in which the highest‐risk patients seemed to benefit most, a finding that supports the importance of assessing risk and appropriately dosing interventions.41 Another recent study in a socioeconomically disadvantaged population suggests the utility of an alternate transitional care approach centered on a pharmacy‐based intervention.30

Ours is essentially a test‐of‐concept study, with several important limitations, which should temper widespread application of these results and suggest the need for further study. The sample size of our study was limited, and this, coupled with a slightly lower‐than‐expected event rate, limits our ability to detect potentially important effects. Our study was not a randomized trial, and we cannot discount the possibility that our results reflect the effect of residual or unmeasured confounders, especially those factors such as patient volume and care quality related to the discharging hospitals themselves. We attempted to minimize the effects of such confounders by balancing the types of hospitals included in each group, and by accounting for clustering by hospital in our statistical analysis. Important differences in baseline characteristics between the 2 groups also raise the possibility of residual confounding despite multivariate adjustment. However, the intervention group generally carried a higher burden of illness which would, if anything, have biased results towards the null. The pragmatic study design necessitated an intervention that was defined broadly and left much to the discretion of the staff delivering the intervention, rather than adherence to a strictly defined protocol. We believe this approach allows evaluation of systems innovations within limited‐resource settings, but we acknowledge the challenges this presents in applying study results to other settings. Finally, only approximately 1 in 4 intervention patients were successfully contacted and completed the post‐discharge survey within 1 week. The relatively low rate of successful telephone contact underscores the difficulty of implementing transitional care interventions dependent on post‐discharge contact in a socioeconomically disadvantaged population with unstable telephone access. Because only successfully contacted patients were included in the intervention group, selection bias is a potential issue, though again, most baseline discrepancies between the 2 groups suggest that intervention patients were more complex.

Transitions of care in uninsured and publicly insured nonelderly adults should be studied in greater depth. Outpatient access to care deficiencies may be compounded in these groups, especially as states face widespread budget crises. Future studies should examine the effects of inpatient to outpatient linkages for such patients. Also, studies should assess the impact of transitional care interventions on self‐management, quality of care, and intermediate health outcomes in the outpatient setting after hospital discharge. Future research should taxonomize the range of transitional care needs by qualitatively evaluating subgroups of patients and delineating challenges faced by each group. For example, the post‐discharge needs of marginally housed patients may be unique and could inform the development of interventions specifically targeted to this group.

In summary, we found that a simple, brief‐touch intervention and needs assessment in the post‐discharge period may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse post‐discharge care needs, though the exact mechanisms responsible for the observed improvements are unclear. Future studies should evaluate transitional care interventions targeted to needs in a larger group of chronically ill patients.

The inpatient to outpatient transition marks an abrupt paradigm shift from intensive, provider‐initiated care to self‐managed care, in which patients are primarily responsible for maintaining day‐to‐day health behaviors, following through with outpatient appointments, and negotiating medications, transport, and equipment needs. Studies indicate that medication nonadherence and medication‐related adverse events are common during the post‐discharge period, and may be related to the discontinuities associated with transitions of care.110

Given the complexity and uncertainty inherent in care transitions for patients with chronic illness, it is not surprising that poorly executed care transitions have been associated with increased risk of rehospitalizations and emergency department (ED) use.11 Patients with chronic illness are at particularly high risk for recurrent hospitalization.1114 System‐wide improvements in chronic illness care have been successful in triaging longitudinally followed, high‐risk outpatients to appropriate higher‐intensity care management interventions.1519 But the post‐discharge setting presents unique challenges for patients with chronic illness, especially those that are socioeconomically disadvantaged. External barriers, such as lack of transportation, lack of monitoring equipment, confusion about arranging follow‐up care, uncertainty about medication regimen changes, and financial constraints, represent important targets for improving care in the transition from inpatient to outpatient settings.

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as members transfer between different locations or different levels of care.20 Most successful transitional care interventions have focused on geriatric populations or patients with congestive heart failure enrolled in health maintenance organizations, and have involved intensive nurse case management from the hospital setting through the post‐discharge period.2125 In these studies, trained nurse case managers provided critical support and patient education to improve patients' ability to self‐manage chronic illness.2629

In a resource‐poor Medicaid payment structure, the implementation of intensive care management across a broad population of patients may not be practical; alternative options for intervention dosing and implementation may be needed. Few studies have examined care needs and the impact of transitional care interventions in socioeconomically disadvantaged patients with chronic illness, though a recent study including such a population did find benefit from a pharmacist‐based intervention.30 The purpose of our study was to examine the impact of a low‐cost, post‐discharge needs assessment, as an adjunct to an existing care management program, on the risk of recurrent hospitalization in a clinically diverse cohort of chronically ill Medicaid managed care enrollees.

METHODS

RESULTS

We enrolled 97 intervention and 130 control patients. Follow‐up utilization data were available for all patients. Table 1 compares sociodemographic, utilization, and comorbidity characteristics of the 2 groups, and Table 2 summarizes patient distribution and characteristics of the hospitals from which they were discharged. The control group was significantly older and more racially diverse than the intervention group. On the other hand, the intervention group had a higher burden of illness as suggested by higher ACG scores and a higher rate of hospitalization within the previous year. Most patients had been hospitalized at large, urban hospitals.

Patients in the intervention group had a slightly lower 60‐day rehospitalization rate compared to the control group, but this difference was not statistically significant in unadjusted analyses (Table 3; 23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24‐1.00].

Nearly half the intervention patients received one or more brief‐touch interventions (48.5%), and the majority of patients (61.7%) receiving a brief‐touch intervention did not require referral to care management. Table 4 lists examples of brief‐touch interventions received by patients. More patients in the intervention group than in the control group were enrolled in the CareSupport care management program (40.2% vs 14.6%, P < 0.001), and about half (53.8%) of the intervention patients referred for care management did not receive a brief‐touch intervention. Patients enrolled in care management were slightly younger (mean age 56.7 vs 59.1 years, P = 0.16), but had a higher burden of illness (mean ACG score 0.53 vs 0.40, P = 0.006) than those not enrolled in care management.

More patients in the intervention group compared to control patients had one or more primary care visits within the year after hospital discharge (86.6% vs 72.3%, P = 0.01), and within 60 days after hospital discharge (68.0% vs 58.5%, P = 0.14), though the latter difference did not reach statistical significance. Interestingly, in an exploratory analysis, we found that hospitalization was more likely to introduce discontinuities in longitudinal primary care in control patients than in intervention patients: among patients who had had 3 or more primary care visits in the year prior to hospitalization, control patients were more likely than intervention patients to have 2 or fewer primary care visits during the year following hospitalization (33.8% vs 20.6%, P = 0.03).

Our mediation analyses suggested that neither post‐hospitalization primary care utilization within 60 days nor care management services accounted for the lower rate of recurrent hospitalization in the intervention group (Table 3). The addition of post‐hospitalization primary care utilization to the original model did not change the primary effect estimate, while controlling for care management enrollment actually increased the effect size. Finally, there was no difference in readmission rates between those receiving and not receiving brief‐touch interventions (31.8 vs 25.7%, P = 0.92).

DISCUSSION

We found that a simple, telephone‐based, transitional care intervention may be associated with lower 60‐day rehospitalization rates in a cohort of Medicaid managed care patients. We observed a reduced rate of readmissions in the intervention, a difference that became significant after adjustment for important confounders. Implicit in the design of the intervention was a recognition that patients' transitional care needs may vary, from help negotiating the post‐discharge follow‐up care process to more substantial and complex care management support needs. Our study adds to the current body of literature by examining an understudied, socioeconomically disadvantaged population in a resource‐poor health system. Importantly, our study targeted the most intensive intervention to those with the highest anticipated needs based on a simple triage scheme. Such targeted approaches may be especially important in resource‐poor settings.

Although our study was too small to characterize in detail the relative importance of specific elements of our intervention responsible for lower short‐term rehospitalization rates, the study does highlight the diversity of transitional care needs. Patients received logistic support negotiating the health system, preventive health promotion, and patient empowerment through self‐management and information access training. Nearly half the patients received a documented simple telephone‐based intervention, and many of these patients did not require referral for intensive nurse care management. On the other hand, our needs assessment did identify over one‐third of recently discharged patients as having more complex chronic disease management needs requiring assessment for ongoing nurse care management.

We were not able to identify the specific aspects of the intervention responsible for the observed reduction in recurrent hospitalization. Our mediation analysis suggests that triaging patients to a nurse care management program was not responsible for the observed reduction in recurrent hospitalizations. In fact, the analysis suggests these patients may have been more likely to require hospitalization, though our study was too small to allow strong conclusions to be drawn from a subgroup analysis. Past studies have similarly suggested that patients enrolled in care management may simply have a higher burden of disease or may have the need for hospitalization recognized more frequently.36 Readmission rates were also similar between patients who did and did not receive a brief‐touch intervention, possibly suggesting that patients with a higher level of need were appropriately selected to receive assistance.

Although our intervention appeared to increase post‐discharge follow‐up in primary care, this also did not explain the observed reduction in 60‐day rehospitalization rates. Despite differences in post‐discharge outpatient utilization patterns, there were relatively few patients in either group that had no follow‐up, and the lack of effect may simply reflect inadequate power given our small sample size. On the other hand, the lack of association between outpatient utilization and 60‐day rehospitalization rates may reflect a true lack of association between primary care follow‐up and rehospitalization as seen in some studies, though a larger Medicare study did find an association.3638

Improvements in outpatient utilization patterns, as we saw in this study, may be a laudable intermediate outcome benefit despite the lack of association with 60‐day rehospitalization rates in our study. Short‐term rehospitalization rates represent only one outcome and do not capture the expected slow, iterative benefits from chronic illness risk reduction, which may accrue over time, with stable longitudinal primary care and associated outpatient chronic illness care systems' innovations.15, 31, 39, 40

Recent studies of transitional care interventions in publicly insured adults have produced mixed results. An evaluation of Medicare demonstration projects found largely negative results, but did find 2 successful programs in which the highest‐risk patients seemed to benefit most, a finding that supports the importance of assessing risk and appropriately dosing interventions.41 Another recent study in a socioeconomically disadvantaged population suggests the utility of an alternate transitional care approach centered on a pharmacy‐based intervention.30

Ours is essentially a test‐of‐concept study, with several important limitations, which should temper widespread application of these results and suggest the need for further study. The sample size of our study was limited, and this, coupled with a slightly lower‐than‐expected event rate, limits our ability to detect potentially important effects. Our study was not a randomized trial, and we cannot discount the possibility that our results reflect the effect of residual or unmeasured confounders, especially those factors such as patient volume and care quality related to the discharging hospitals themselves. We attempted to minimize the effects of such confounders by balancing the types of hospitals included in each group, and by accounting for clustering by hospital in our statistical analysis. Important differences in baseline characteristics between the 2 groups also raise the possibility of residual confounding despite multivariate adjustment. However, the intervention group generally carried a higher burden of illness which would, if anything, have biased results towards the null. The pragmatic study design necessitated an intervention that was defined broadly and left much to the discretion of the staff delivering the intervention, rather than adherence to a strictly defined protocol. We believe this approach allows evaluation of systems innovations within limited‐resource settings, but we acknowledge the challenges this presents in applying study results to other settings. Finally, only approximately 1 in 4 intervention patients were successfully contacted and completed the post‐discharge survey within 1 week. The relatively low rate of successful telephone contact underscores the difficulty of implementing transitional care interventions dependent on post‐discharge contact in a socioeconomically disadvantaged population with unstable telephone access. Because only successfully contacted patients were included in the intervention group, selection bias is a potential issue, though again, most baseline discrepancies between the 2 groups suggest that intervention patients were more complex.

Transitions of care in uninsured and publicly insured nonelderly adults should be studied in greater depth. Outpatient access to care deficiencies may be compounded in these groups, especially as states face widespread budget crises. Future studies should examine the effects of inpatient to outpatient linkages for such patients. Also, studies should assess the impact of transitional care interventions on self‐management, quality of care, and intermediate health outcomes in the outpatient setting after hospital discharge. Future research should taxonomize the range of transitional care needs by qualitatively evaluating subgroups of patients and delineating challenges faced by each group. For example, the post‐discharge needs of marginally housed patients may be unique and could inform the development of interventions specifically targeted to this group.

In summary, we found that a simple, brief‐touch intervention and needs assessment in the post‐discharge period may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse post‐discharge care needs, though the exact mechanisms responsible for the observed improvements are unclear. Future studies should evaluate transitional care interventions targeted to needs in a larger group of chronically ill patients.