title: Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients.
abstract: BACKGROUND
  Uninsured and Medicaid patients are particularly vulnerable as they transition from hospital to home. Transitional care improvement programs require time and capital, incentives for which may be unclear for those lacking a third-party payor. This article describes our experience developing a hospital-funded transitional care program for uninsured and Medicaid patients.
  
  
  METHODS
  We performed an inpatient needs assessment, convened multi-stakeholder work groups, and engaged institutional change-agents to inform program development and a business case.
  
  
  RESULTS
  We mapped needs to specific program elements, including a transitional care nurse, pharmacy consult and provision of medications for uninsured patients, medical home linkages including community payment for medical homes, and monthly quality improvement meetings. A business case was informed by local needs and utilization data, and compelled the hospital to invest in up-front resources for this population.
  
  
  CONCLUSIONS
  We are studying our program's impact on 30-day readmission and emergency department rates through a clustered, randomized controlled trial. Lessons from our experience may be useful to others aiming to improve care for socioeconomically disadvantaged patients.
authors.affiliation: Departments of Medicine, Oregon Health & Science University (Englander/Kansagara) and Portland VA Medical Center (Kansagara), Portland, OR, USA. englandh@ohsu.edu
authors.forename: Honora
authors.initials: H
authors.lastname: Englander
authors.forename: Devan
authors.initials: D
authors.lastname: Kansagara
mesh_terms: D003266:Continuity of Patient Care; D004059:Diffusion of Innovation; D006285:Health Planning / Q000379:methods*; D006699:Home Care Services; D006760:Hospitalization; D006801:Humans; D007297:Inpatients; D008484:Medicaid; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D020380:Needs Assessment; D010351:Patient Discharge / Q000706:statistics & numerical data*; D018802:Patient-Centered Care; D010865:Pilot Projects; D015397:Program Evaluation; D014481:United States