• Online Features  This Article  • Full text  • PDF  • Reply to article  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (167)  • Contact me when this article is cited  Related Content  • Related articles  • Similar articles in this journal  Topic Collections  • Aging/ Geriatrics  • Alert me on articles by topic  Social Bookmarking   What's this?

Results of a Randomized Controlled Trial

Eric A. Coleman, MD, MPH; Carla Parry, PhD, MSW; Sandra Chalmers, MPH; Sung-joon Min, PhD

Arch Intern Med. 2006;166:1822-1828.

Background  Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates.

Methods  Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a "transition coach." Rates of rehospitalization were measured at 30, 90, and 180 days.

Results  Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P = .048) and at 90 days (16.7 vs 22.5, P = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P = .04) and at 180 days (8.6 vs 13.9, P = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P = .049).

Conclusion  Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.

Trial Registration  clinicaltrials.gov Identifier: NCT00244491

Author Affiliations: Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver.

CiteULike    Connotea    Delicious    Digg    Facebook    Reddit    Technorati    Twitter     What's this?

RELATED ARTICLES

Improving Medication Adherence: Challenges for Physicians, Payers, and Policy Makers
Patrick J. O’Connor
Arch Intern Med. 2006;166(17):1802-1804.
EXTRACT | FULL TEXT  

Cost-Related Medication Nonadherence Among Elderly and Disabled Medicare Beneficiaries: A National Survey 1 Year Before the Medicare Drug Benefit
Stephen B. Soumerai, Marsha Pierre-Jacques, Fang Zhang, Dennis Ross-Degnan, Alyce S. Adams, Jerry Gurwitz, Gerald Adler, and Dana Gelb Safran
Arch Intern Med. 2006;166(17):1829-1835.
ABSTRACT | FULL TEXT  

Effect of Medication Nonadherence on Hospitalization and Mortality Among Patients With Diabetes Mellitus
P. Michael Ho, John S. Rumsfeld, Frederick A. Masoudi, David L. McClure, Mary E. Plomondon, John F. Steiner, and David J. Magid
Arch Intern Med. 2006;166(17):1836-1841.
ABSTRACT | FULL TEXT  

Impact of Medication Therapy Discontinuation on Mortality After Myocardial Infarction
P. Michael Ho, John A. Spertus, Frederick A. Masoudi, Kimberly J. Reid, Eric D. Peterson, David J. Magid, Harlan M. Krumholz, and John S. Rumsfeld
Arch Intern Med. 2006;166(17):1842-1847.
ABSTRACT | FULL TEXT  

Improved Therapeutic Monitoring With Several Interventions: A Randomized Trial
Adrianne C. Feldstein, David H. Smith, Nancy Perrin, Xiuhai Yang, Mary Rix, Marsha A. Raebel, David J. Magid, Steven R. Simon, and Stephen B. Soumerai
Arch Intern Med. 2006;166(17):1848-1854.
ABSTRACT | FULL TEXT  

Physician Communication When Prescribing New Medications
Derjung M. Tarn, John Heritage, Debora A. Paterniti, Ron D. Hays, Richard L. Kravitz, and Neil S. Wenger
Arch Intern Med. 2006;166(17):1855-1862.
ABSTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Do Timely Outpatient Follow-up Visits Decrease Hospital Readmission Rates?
Kashiwagi et al.
American Journal of Medical Quality 2012;27:11-15.
ABSTRACT  

Assisting Patients to Age in Place: An Innovative Pilot Program Utilizing the Patient Centered Care Model (PCCM) in Home Care
Silver et al.
Home Health Care Management Practice 2011;23:446-453.
ABSTRACT  

The Relationship Between Intervening Hospitalizations and Transitions Between Frailty States
Gill et al.
J Gerontol A Biol Sci Med Sci 2011;66A:1238-1243.
ABSTRACT | FULL TEXT  

Risk Prediction Models for Hospital Readmission: A Systematic Review
Kansagara et al.
JAMA 2011;306:1688-1698.
ABSTRACT | FULL TEXT  

Interventions to Reduce 30-Day Rehospitalization: A Systematic Review
Hansen et al.
ANN INTERN MED 2011;155:520-528.
ABSTRACT | FULL TEXT  

Improving Improvement for Childhood Asthma
Homer
JAMA 2011;306:1487-1488.
FULL TEXT  

A Regional Health Collaborative Formed By NewYork-Presbyterian Aims To Improve The Health Of A Largely Hispanic Community
Carrillo et al.
Health Aff (Millwood) 2011;30:1955-1964.
ABSTRACT | FULL TEXT  

Using Patients to Promote Evidence-Based Prescribing: Comment on "Communicating Uncertainties About Prescription Drugs to the Public"
Steinman
Arch Intern Med 2011;171:1468-1469.
FULL TEXT  

A Qualitative Analysis of an Advanced Practice Nurse-Directed Transitional Care Model Intervention
Bradway et al.
The Gerontologist 2011;0:gnr078v1-gnr078.
ABSTRACT | FULL TEXT  

The Effect of an Inpatient Transition Intervention on Attendance at the First Appointment Postdischarge From a Psychiatric Hospitalization
Batscha et al.
J Am Psychiatr Nurses Assoc 2011;17:330-338.
ABSTRACT  

Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions
Lehnert et al.
Med Care Res Rev 2011;68:387-420.
ABSTRACT  

Interventions to Decrease Hospital Readmission Rates: Who Saves? Who Pays?
Katz
Arch Intern Med 2011;171:1230-1231.
FULL TEXT  

The Care Transitions Intervention: Translating From Efficacy to Effectiveness
Voss et al.
Arch Intern Med 2011;171:1232-1237.
ABSTRACT | FULL TEXT  

Effectiveness and Cost of a Transitional Care Program for Heart Failure: A Prospective Study With Concurrent Controls
Stauffer et al.
Arch Intern Med 2011;171:1238-1243.
ABSTRACT | FULL TEXT  

Reducing Readmission Rates: Does Coronary Artery Bypass Graft Surgery Provide Clarity?
Rumsfeld and Allen
J Am Coll Cardiol Intv 2011;4:577-578.
FULL TEXT  

An Administrative Claims Measure Suitable for Profiling Hospital Performance Based on 30-Day All-Cause Readmission Rates Among Patients With Acute Myocardial Infarction
Krumholz et al.
Circ Cardiovasc Qual Outcomes 2011;4:243-252.
ABSTRACT | FULL TEXT  

Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care
Joynt et al.
JAMA 2011;305:675-681.
ABSTRACT | FULL TEXT  

Hospital Readmission as an Accountability Measure
Axon and Williams
JAMA 2011;305:504-505.
FULL TEXT  

Complexity of Family Caregiving and Discharge Planning
Popejoy
Journal of Family Nursing 2011;17:61-81.
ABSTRACT  

Readmission after stroke in a hospital-based registry: Risk, etiologies, and risk factors
Lin et al.
Neurology 2011;76:438-443.
ABSTRACT | FULL TEXT  

Finding the Right Level of Posthospital Care: "We Didn't Realize There Was Any Other Option for Him"
Kane
JAMA 2011;305:284-293.
ABSTRACT | FULL TEXT  

Policy Options to Improve Discharge Planning and Reduce Rehospitalization
Mor and Besdine
JAMA 2011;305:302-303.
FULL TEXT  

Defragmenting Care
Jencks
ANN INTERN MED 2010;153:757-758.
FULL TEXT  

Medicare Readmissions Policies and Racial and Ethnic Health Disparities: A Cautionary Tale
McHugh et al.
Policy Politics Nursing Practice 2010;11:309-316.
ABSTRACT  

Outpatient Follow-up Visit and 30-Day Emergency Department Visit and Readmission in Patients Hospitalized for Chronic Obstructive Pulmonary Disease
Sharma et al.
Arch Intern Med 2010;170:1664-1670.
ABSTRACT | FULL TEXT  

Transitional Case Management: A Method for Establishing Self-Advocacy and Reducing Hospital Readmissions in COPD Patients
Kilgore
Home Health Care Management Practice 2010;22:435-438.
ABSTRACT  

National Patterns of Risk-Standardized Mortality and Readmission for Acute Myocardial Infarction and Heart Failure: Update on Publicly Reported Outcomes Measures Based on the 2010 Release
Bernheim et al.
Circ Cardiovasc Qual Outcomes 2010;3:459-467.
ABSTRACT | FULL TEXT  

Care Management's Challenges and Opportunities to Reduce the Rapid Rehospitalization of Frail Community-Dwelling Older Adults
Golden et al.
The Gerontologist 2010;50:451-458.
ABSTRACT | FULL TEXT  

Lessons For The New CMS Innovation Center From The Medicare Health Support Program
Barr et al.
Health Aff (Millwood) 2010;29:1305-1309.
ABSTRACT | FULL TEXT  

Prior Hospitalization and the Risk of Heart Attack in Older Adults: A 12-Year Prospective Study of Medicare Beneficiaries
Wolinsky et al.
J Gerontol A Biol Sci Med Sci 2010;65A:769-777.
ABSTRACT | FULL TEXT  

ANALYSIS & COMMENTARY The Foundation That Health Reform Lays For Improved Payment, Care Coordination, And Prevention
Thorpe and Ogden
Health Aff (Millwood) 2010;29:1183-1187.
ABSTRACT | FULL TEXT  

Delays in Filling Clopidogrel Prescription After Hospital Discharge and Adverse Outcomes After Drug-Eluting Stent Implantation: Implications for Transitions of Care
Ho et al.
Circ Cardiovasc Qual Outcomes 2010;3:261-266.
ABSTRACT | FULL TEXT  

Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community
van Walraven et al.
CMAJ 2010;182:551-557.
ABSTRACT | FULL TEXT  

Moving beyond the notion of 'self' care
Piette
Chronic Illness 2010;6:3-6.
 

Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study
Schnipper et al.
Circ Cardiovasc Qual Outcomes 2010;3:212-219.
ABSTRACT | FULL TEXT  

Home Is Where the Health Is: Advancing Team-Based Care in Chronic Disease Management
Lipton
Arch Intern Med 2009;169:1945-1948.
FULL TEXT  

A Review of Discharge Planning Research of Older Adults 1990-2008
Popejoy et al.
West J Nurs Res 2009;31:923-947.
ABSTRACT  

Senescent Swallowing: Impact, Strategies, and Interventions
Ney et al.
Nutr Clin Pract 2009;24:395-413.
ABSTRACT | FULL TEXT  

Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials
Peikes et al.
JAMA 2009;301:603-618.
ABSTRACT | FULL TEXT  

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial
Jack et al.
ANN INTERN MED 2009;150:178-187.
ABSTRACT | FULL TEXT  

Coping Difficulties After Hospitalization
Fitzgerald Miller et al.
Clin Nurs Res 2008;17:278-296.
ABSTRACT  

Postdischarge Environmental and Socioeconomic Factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries
Arbaje et al.
The Gerontologist 2008;48:495-504.
ABSTRACT | FULL TEXT  

Seeking What's Best During the Transition to Adult Day Health Services
Bull and McShane
Qual Health Res 2008;18:597-605.
ABSTRACT  

Evidence for Improving Palliative Care at the End of Life: A Systematic Review
Lorenz et al.
ANN INTERN MED 2008;148:147-159.
ABSTRACT | FULL TEXT  

Patterns and predictors of statin use after coronary artery bypass graft surgery.
Kulik et al.
J. Thorac. Cardiovasc. Surg. 2007;134:932-938.
ABSTRACT | FULL TEXT  

Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care
Kripalani et al.
JAMA 2007;297:831-841.
ABSTRACT | FULL TEXT  

Other articles noted
Evid. Based Med. 2007;12:31-32.
FULL TEXT  

Improving medication adherence: challenges for physicians, payers, and policy makers.
O'Connor
Arch Intern Med 2006;166:1802-1804.
FULL TEXT