Results Summary
What was the research about?
When patients go home after a hospital stay, they may still need help. Patients who can’t take care of themselves at home are more likely to go back to the hospital within the first month of going home.
In this study, the research team tested a program to coach and support patients to take care of themselves after going home from the hospital. The program had several parts:
- A pharmacist taught patients about the medicine they would be taking at home.
- A nurse helped patients get ready for being at home.
- A visiting nurse or pharmacist visited patients at home.
- A nurse from patients’ regular doctors’ offices checked in with patients, coached patients by phone or video calls, and saw patients during any follow-up doctor visits.
The team compared this program with the usual care that patients got when leaving the hospital.
What were the results?
The study found no difference between patients who were in the program and those who got usual care in how often patients had to go back to the hospital within a month of going home. Patients who were in the program had fewer new or worse symptoms and fewer adverse events within a month of going home compared with patients who got usual care. An adverse event is an injury or other problem that results from the care patients receive rather than their health problems.
There was no difference between patients who were in the program and those who got usual care in how patients felt about the care they received.
Who was in the study?
The study included 1,657 adult patients at two hospitals in Massachusetts. Each patient was seeing a doctor at 1 of 18 offices. Of these patients, 54 percent were women, 74 percent were white, and 26 percent were other races.
What did the research team do?
The research team assigned the 18 doctors’ offices by chance to start the program at different times during the study. Next, the team looked at hospital records to compare patients within the same doctors’ offices before and after the offices started to use the program. Patients also took a telephone survey one month after going home from the hospital.
An advisory group gave the team input during the study. The group included patients who had recently been in the hospital and caregivers of patients who had been in the hospital.
What were the limits of the study?
The hospitals and doctors’ offices didn’t all carry out the program as planned. For example, not all the hospitals and doctors’ offices used all parts of the program or started the program on time. It is hard to tell how the program might have worked if the hospitals and doctors’ offices had carried the program out as planned.
Future research can look at the best way to help hospitals and doctors’ offices help patients when they leave the hospital.
How can people use the results?
Researchers can use these results to identify other ways of supporting patients when going home from the hospital. This support may help patients avoid having their health problems get worse.
Professional Abstract
Objective
To evaluate the effectiveness of a multistep, collaborative transitional care intervention on patient outcomes after hospital discharge compared with usual care
Study Design
Design Element | Description |
---|---|
Design | Stepped-wedge cluster randomized trial |
Population | 1,657 patients admitted to medical and surgical services at 1 of 2 hospitals in the same ACO |
Interventions/ Comparators |
|
Outcomes |
Primary: nonelective 30-day hospital readmissions, postdischarge new or worsening signs or symptoms, postdischarge adverse events Secondary: patient experience |
Timeframe | 30-day follow-up for primary outcomes |
This randomized trial tested the effects of a new multistep, collaborative transitional care intervention developed to improve outcomes for patients transitioning from hospital to home. The study included 18 primary care practices (PCPs) that were part of the same Accountable Care Organization (ACO) and used a patient-centered medical home (PCMH) model. Researchers rolled out the intervention sequentially to the study sites in a stepped-wedge design and randomly assigned PCPs a time during the study period to begin the intervention.
The study included 1,657 adult patients who had providers from 1 of 18 participating PCPs. Patients had been admitted to medical and surgical services at two Massachusetts hospitals within the same ACO as the PCPs. Of these patients, 54% were female, 74% were white, and 26% were other races.
The intervention had several parts, including
- Inpatient pharmacist-led medication reconciliation and counseling
- Coordination of care and patient education from a nurse inpatient-discharge advocate
- In-home nurse and/or pharmacist visits for patients who were homebound or needed these extra services
- Responsible outpatient clinicians, usually nurses, who took over the coordination of care once the patient was home, providing coaching or checking in with the patient by telephone or video conference
- Follow-up clinic visits with the entire multidisciplinary team
Usual care consisted of the typical care the PCMH provides to patients as transitional care.
To assess hospital readmissions, the research team used hospital administrative data and surveys. Patients completed the telephone surveys within 30 days after discharge to report new or worsening symptoms and patient experience, including their participation in, understanding of, and ability to carry out the postdischarge care plan. Physician adjudicators reviewed all cases of new or worsening signs or symptoms to confirm or deny the presence of any postdischarge adverse events, defined as patient injury due to medical care rather than the patient’s underlying medical conditions.
A patient and caregiver advisory group provided input throughout the study.
Results
The research team found no difference between groups in hospital readmissions within 30 days of discharge. Compared with usual care, the transitional care intervention was associated with a 22% lower rate of new or worsening signs or symptoms 30 days postdischarge (p=0.01) and a 48% reduction in postdischarge adverse events (p=0.02).
There were no differences between groups in patient experience survey responses.
Limitations
The research team found inconsistent implementation of the intervention components in inpatient and outpatient settings as well as variation by hospitals and PCPs. In addition, not all study sites implemented the intervention at the time scheduled. If all sites implemented the intervention as intended, findings may have been different. Patients at risk for poor postdischarge outcomes may have had more transitional care interventions put in place than patients at less risk for poor outcomes, potentially biasing the study results.
Conclusions and Relevance
The transitional care intervention did not affect rates of hospital readmission compared with usual care; however, the study findings suggest that a collaborative transitional care intervention can help reduce new and worsening postdischarge signs and symptoms as well as adverse events.
Future Research Needs
Future research could examine the effectiveness of the intervention when study sites implement all elements of the intervention together consistently.
Final Research Report
View this project's final research report.
Journal Citations
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Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer-review process here.
In response to peer review, the PI made changes including
- Providing more examples of the study’s stakeholder engagement, specifically related to how stakeholder partners participated in the development of the intervention. In response to reviewer concerns, researchers also acknowledged in the Discussion that increasing stakeholder influence earlier in the design process could have led to a stronger intervention, perhaps with more pronounced effects in this study.
- Highlighting the importance of tailoring the intervention to each patient’s level of health literacy, in response to reviewer concerns about lack of clarity in the report.
- Adding more description of the individual recruitment process and the study timeline in response to reviewer questions about how individual patients were recruited in a study testing interventions being deployed at the clinic level.
- Specifying how baseline covariate data were collected about each data point in an existing table.
- Elaborating on the possibility that the outcome adjudication processes changed over time. The researchers noted in the Methods and Limitations that although they made every effort to keep the adjudicators blinded to who received which intervention, the people filling this role might have determined that with a stepped design, patients with later hospitalizations were more likely to be in the intervention group.
- Acknowledging in the Limitations discussion that the stepped wedge design of the study could be subject to temporal trends in healthcare delivery, such that the later starting sites would be affected by changing healthcare policy. In response to reviewers about this issue, the researchers also noted the ways that they endeavored to reduce this potential limitation through maintaining a short study period for each study site.