The care transitions intervention: translating from efficacy to effectiveness

Arch Intern Med. 2011 Jul 25;171(14):1232-7. doi: 10.1001/archinternmed.2011.278.


Background: Well-executed communication among hospital providers, patients, and receiving providers at the time of hospital discharge contributes to better health outcomes and lower overall health care costs. The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system but requires real-world testing to establish effectiveness in other settings. We hypothesized that coaching would reduce 30-day readmission rates for fee-for-service Medicare beneficiaries, even in open, urban health care delivery systems.

Methods: This was a quasi-experimental prospective cohort study. From January 1, 2009, through June 30, 2010, coaches recruited a convenience sample of fee-for-service Medicare patients in 6 Rhode Island hospitals to receive the Care Transitions Intervention. We paired coaching data with Medicare claims and enrollment data and used logistic regression to compare the odds of 30-day readmission for the intervention group vs internal and external control groups.

Results: Compared with individuals who did not receive any part of the intervention (20.0% readmission rate), 30-day readmissions were fewer for participants who received coaching (12.8%; odds ratio, 0.61; 95% confidence interval, 0.42-0.88). Individuals in the internal control group (declined to participate or were lost to follow-up before completing a home visit) had readmission rates similar to those of the external control group (18.6%; odds ratio, 0.94, 95% confidence interval, 0.77-1.14).

Conclusions: The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Advanced Practice Nursing
  • Aged
  • Aged, 80 and over
  • Continuity of Patient Care* / trends
  • Fee-for-Service Plans
  • Female
  • Hospitals, Community / statistics & numerical data
  • Hospitals, Teaching / statistics & numerical data
  • Humans
  • Logistic Models
  • Male
  • Medicare
  • Middle Aged
  • Odds Ratio
  • Outcome Assessment, Health Care
  • Patient Discharge / standards*
  • Patient Education as Topic / methods*
  • Patient Education as Topic / standards
  • Patient Education as Topic / trends
  • Patient Readmission / economics
  • Patient Readmission / statistics & numerical data*
  • Prospective Studies
  • Rhode Island / epidemiology
  • Sampling Studies
  • Social Work
  • United States
  • Urban Population / statistics & numerical data