Journal of the American Geriatrics Society

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Eric A. Coleman MD, MPH

From the Divisions of *Health Care Policy and Research†Geriatric Medicine, University of Colorado Health Sciences Center, Denver, Colorado‡Multicampus Division of Geriatric Medicine and Gerontology, University of California at Los Angeles, Los Angeles, California.

Search for more papers by this author

Jodi D. Smith ND, GNP,

Jodi D. Smith ND, GNP

Search for more papers by this author

Janet C. Frank DrPH,

Janet C. Frank DrPH

Search for more papers by this author

Sung-Joon Min AM,

Sung-Joon Min AM

Search for more papers by this author

Carla Parry PhD, MSW,

Carla Parry PhD, MSW

Search for more papers by this author

Andrew M. Kramer MD,

Andrew M. Kramer MD

Search for more papers by this author

Eric A. Coleman MD, MPH,

Eric A. Coleman MD, MPH

Search for more papers by this author

Jodi D. Smith ND, GNP,

Jodi D. Smith ND, GNP

Search for more papers by this author

Janet C. Frank DrPH,

Janet C. Frank DrPH

Search for more papers by this author

Sung-Joon Min AM,

Sung-Joon Min AM

Search for more papers by this author

Carla Parry PhD, MSW,

Carla Parry PhD, MSW

Search for more papers by this author

Andrew M. Kramer MD,

Andrew M. Kramer MD

Search for more papers by this author

First published: 26 October 2004

https://doi.org/10.1111/j.1532-5415.2004.52504.x

Citations: 415

Eric A. Coleman, MD, MPH, Divisions of Health Care Policy and Research and Geriatric Medicine, University of Colorado Health Sciences Center, 13611 East Colfax Avenue, Suite 100, Aurora, CO 80011. E-mail: http://www.oig.hhs.gov/reports.html

Funded by The Robert Wood Johnson Foundation Grant 041863, National Institute on Aging Grant AG019652, and the Paul Beeson Faculty Scholar in Aging Research/American Federation for Aging Research.

Share a link

Email
Facebook
Twitter
LinkedIn
Reddit
Wechat

Abstract

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates.

Design: Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235).

Setting: A large integrated delivery system in Colorado.

Participants: Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions.

Intervention: Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach.

Measurements: Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects' care experience was assessed using the care transitions measure.

Results: The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28–0.96) at 30 days, 0.43 (95% CI=0.25–0.72) at 90 days, and 0.57 (95% CI=0.36–0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen.

Conclusion: Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.

References

1 Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003; 51: 556–557.
2 Coleman EA. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003; 51: 549–555.
3 Institute of Medicine. Crossing the Quality Chasm: A New Health System of the 21st Century. Washington, DC: National Academy Press, 2001.
4 Boling P. The value of targeted case management during transitional care. JAMA 1999; 281: 656–657.
5 Forster A, Murff H, Peterson J et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138: 161–167.
6 Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD: Johns Hopkins University, 2002.
7 Harrison A, Verhoef M. Understanding coordination of care from the consumer's perspective in a regional health system. Health Serv Res 2002; 37: 1031–1054.
8 Levine C. Rough Crossings: Family Caregivers Odysseys through the Health Care System. New York: United Hospital Fund of New York, 1998.
9 Coleman EA, Eilertsen TB, Smith JD et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integrated Care 2002; 2: 1–8.
10 Moore C, Wisnevesky J, Williams S et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003; 18: 646–651.
11 Weissman J, Ayanian J, Chasan-Taber S et al. Hospital readmissions and quality of care. Med Care 1999; 37: 490–501.
12 Corrigan J, Martin J. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res 1992; 27: 81–101.
13 Roblin D, Juhn P, Preston B et al. A low-cost approach to prospective identification of impending high cost outcomes. Med Care 1999; 37: 1155–1163.
14 Coleman EA, Min S, Chomiak A et al. Post-hospital care transitions: Patterns, complications, and risk identification. Health Serv Res 2004; 39: 1423–1439.
15 Rich M, Beckham V, Wittenberg C et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190–1195.
16 Stewart S, Pearson S, Horowitz J. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 2000; 158: 1067–1072.
17 Naylor M, Brooten D, Campbell R et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999; 281: 613–620.
18 Einstadter D, Cebul RD, Franta PR. Effect of a nurse case manager on postdischarge follow-up. J Gen Intern Med 1996; 11: 684–688.
19 Siu AL, Kravitz RL, Keeler E et al. Postdischarge geriatric assessment of hospitalized frail elderly patients. Arch Intern Med 1996; 156: 76–81.
20 Gage B. Impact of the BBA on post-acute utilization. Health Care Financ Rev 1999; 20: 103–126.
21 Parry C, Coleman EA, Smith JD et al. The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q 2003; 22: 1–14.
22 Lorig K, Gonzalez V, Laurent D. The Chronic Disease Self-Management Workshop. Palo Alto, CA: Stanford University, 1999.
23 Von Korff M, Wagner E, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol 1992; 45: 197–203.
24 Coleman EA, Wagner EH, Grothaus LC et al. Predicting hospitalization and functional decline in older health plan enrollees: Are administrative data as accurate as self-report? J Am Geriatr Soc 1998; 46: 419–425.
25 Coleman EA, Eilertsen TB, Smith JD et al. Developing and testing of a measure designed to assess the quality of care transitions [abstract]. J Am Geriatr Soc 2002; 50 (Suppl 4): S7.
26 Lorig K, Sobel D, Stewart A et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Med Care 1999; 37: 5–14.
27 Von Korff M, Wagner E. The role of the older person in managing illness. In: E Calkins, C Boult, E Wagner et al., eds. New Ways to Care for Older People. New York: Springer, 1999, pp 210–226.
28 Institute of Medicine. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academies Press, 2003.
29 Agency for Health Care Quality Research. Medical Errors: The Scope of the Problem. Rockville, MD: Department of Health and Human Services, 2000.
30 Bazzoli GJ, Brewster LR, Liu G et al. Does U.S. hospital capacity need to be expanded? Health Aff 2003; 22: 40–54.
31 Brewster LR, Rudell LS, Lesser CS. Emergency room diversions: A symptom of hospitals under stress. Issue Brief Cent Stud Health Syst Change 2001; 38: 1–4.
32 Analysis of Readmissions under the Medicare Prospective Payment System for Calendar Years 1996 and 1997 [on-line]. Office of the Inspector General, Department of Health and Human Services. Available at: http://cms.hhs.gov/medicare/hcpcs/ (A-14-99-00401). Accessed November 17, 2003.
33 Medicare Payment Advisory Commission. Using market competition in fee-for-service Medicare. In: Report to Congress. Washington, DC: MedPAC, 2003, pp 131–146.
34 Medicare Payment Advisory Commission. Using incentives to improve the quality of care in Medicare. In: Report to Congress. Washington, DC: MedPAC, 2003, pp 107–127.
35 Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) [on-line]. Available at: http://www.aahp.org/Content/NavigationMenu/Inside_AAHP/Care_Management1/Care_Management.htm Accessed November 17, 2003.
36 HMO Care Management Workgroup. One Patient, Many Places. Managing Healthcare Transitions [on-line]. Available at: [email protected]. Accessed March 21, 2004.

Citing Literature

Volume52, Issue11

November 2004

Pages 1817-1825

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Abstract

References

Citing Literature

References

Information

About Wiley Online Library

Help & Support

Opportunities

Connect with Wiley

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Abstract

References

Citing Literature

References

Related

Information