Professional Abstract

Objective

To test the effectiveness of a patient navigation and peer coaching intervention on improving patient experiences following discharge from the hospital

Study Design

Design Elements	Description
Design	Randomized controlled trial
Population	1,029 patients hospitalized with a heart failure, pneumonia, COPD, myocardial infarction, or sickle cell disease diagnosis
Interventions/ Comparators	In-person patient navigator assistance and telephone peer coaching Usual care
Outcomes	Primary: patient-reported anxiety; patient-reported informational support, defined as the ability to obtain advice, guidance, suggestions, or useful information Secondary: patient-reported mental and physical health; healthcare utilization, including an outpatient visit within 14 days of hospital discharge; ED visit, rehospitalization, or death within 30 or 60 days of discharge
Timeframe	60-day follow-up for primary outcomes

The PATient Navigator to rEduce Readmissions (PArTNER) study compared the effectiveness of a navigator and peer coaching intervention with usual care on improving patient experiences during transition from hospital to home.

Researchers randomly assigned patients to receive the navigator intervention or usual care prior to discharge from the hospital. In the intervention group, two trained individuals—a patient navigator and a peer coach—interacted with patients. Navigators visited patients assigned to the intervention in person before discharge and again within three days after discharge. They helped patients identify barriers to health and health care, reviewed a patient discharge education tool, offered community resources if needed, and promoted self-management skills. Then, peer coaches called patients weekly for up to 60 days after discharge, focusing on overcoming barriers to care and promoting self-management of health.

In usual care, clinical staff provided medication reconciliation on the day of discharge, along with education about the patient’s condition, disease management, medications, and self-care. Patients received a structured discharge summary at the time of discharge.

At baseline prior to discharge and then 30 and 60 days after discharge, researchers collected data on anxiety and informational support using patient-reported outcome measures and assessed healthcare utilization using patients’ medical records.

The study included 1,029 patients receiving care at a hospital in Illinois for heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, myocardial infarction, or sickle cell disease. Of these patients, 82% were black. The average age was 50, and 55% were female.

An advisory committee of patients, caregivers, advocacy groups, clinicians, and researchers helped design the intervention and define study outcomes. Patient advocates served as peer coaches in the study.

Results

At 30 and 60 days after discharge, patients in the navigator program and patients receiving usual care did not differ significantly in the amount of improvement in study outcomes. Compared with baseline, patients in both groups reported improvement in

• Anxiety and information support after 30 days (p<0.01)
• Mental health at 60 days (p<0.01)
• Physical health at 30 and 60 days (p<0.01)

Limitations

About 40% of patients did not receive calls from peer coaches due to patient nonresponse. Findings may be different if more patients had participated in the intervention. The study took place at a single hospital. The results may not be generalizable to other locations.

Conclusions and Relevance

A patient navigator and peer coaching intervention for hospital-to-home transitions did not improve anxiety and informational support more than usual care.

Future Research Needs

Future research could explore other interventions that might improve patient experiences after hospital discharge.