Somnath Saha, MD, MPH

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.