Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting

Home Health Care Serv Q. 2009;28(2-3):84-99. doi: 10.1080/01621420903155924.


The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations--The Care Transitions Intervention--could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Activities of Daily Living
  • Aged
  • Aged, 80 and over
  • Colorado
  • Continuity of Patient Care / organization & administration*
  • Fee-for-Service Plans*
  • Female
  • Home Care Services / organization & administration
  • Humans
  • Male
  • Medicare Part C / organization & administration
  • Nursing Homes / organization & administration
  • Patient Discharge
  • Patient Readmission* / statistics & numerical data
  • United States