Preparing Patients and Caregivers to Participate in Care Delivered Across Settings

The Care Transitions Intervention

Coleman, Eric A. MD, MPH
Smith, Jodi D. ND, GNP
Frank, Janet C. DrPH
Min, Sung-Joon AM
Parry, Carla PhD, MSW
Kramer, Andrew M. MD

^*Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, Colorado
^†Division of 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

Address correspondence to 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.

Journal of the American Geriatrics Society 52(11):p 1817-1825, November 2004.

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.