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.

Final Research Report

View this project's final research report.

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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.

Conflict of Interest Disclosures

Project Information

Jeffrey L. Schnipper, MD, MPH
Brigham and Women's Hospital
Relative Patient Benefits of a Hospital-PCMH Collaboration within an ACO to Improve Care Transitions

Key Dates

December 2012
July 2017

Study Registration Information


Has Results
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Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: April 11, 2024