Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention.
OBJECTIVE
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.


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


METHODS
A large integrated delivery system in Colorado.


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


METHODS
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.


METHODS
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.


CONCLUSIONS
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.
Coleman
Eric A
EA
Division of Health Care Policy and Research, and Geriatric Medicine, University of Colorado Health Sciences Center, 13611 East Colfax Avenue, Aurora, CO 80011, USA. Eric.Coleman@uchsc.edu
Smith
Jodi D
JD
Frank
Janet C
JC
Min
Sung-Joon
SJ
Parry
Carla
C
Kramer
Andrew M
AM
D000368:Aged; D017028:Caregivers; D002908:Chronic Disease / Q000628:therapy*; D003266:Continuity of Patient Care / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D016017:Odds Ratio; D010358:Patient Participation; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012044:Regression Analysis; D012648:Self Care; D018709:Statistics, Nonparametric