Results Summary
What was the research about?
When patients go home from the hospital, having information about what to expect is important for their recovery. Patients may need to know how to plan follow-up care or get help from community organizations.
In this study, the research team compared two ways to help people recover at home after a hospital stay:
- Navigator and peer coach program. In this program, two types of trained professionals helped patients. Patient navigators met with patients once, in person, at the hospital and once at home to talk about patients’ recovery needs. For example, if patients needed help with housing or food, navigators told patients about community resources. Then, peer coaches checked in with patients by phone for six weeks. Peer coaches encouraged patients and helped them with any new questions about their illnesses or their recovery.
- Usual care. Patients learned about their illnesses and went over their medicines with a nurse at the hospital. They also received printed instructions before they left the hospital.
What were the results?
After two months, patients in the two groups reported similar levels of
- Feeling anxious or supported
- Mental or physical health
- Use of healthcare services
The two groups also didn’t differ in how many patients went back to the hospital or died.
After one month, compared to the start of the study, patients in both groups felt less anxious and more supported. After two months, patients in both groups had better mental and physical health.
Who was in the study?
The study included 1,029 patients who were going home from a hospital in Illinois. Of these, 82 percent were black. The average age was 50, and 55 percent were women. Patients were at the hospital for one of five health problems: sickle cell disease, heart failure, pneumonia, chronic obstructive pulmonary disease, or a heart attack.
What did the research team do?
The research team assigned patients to one of two groups by chance. One group took part in the program, and the other group received usual care.
Patients in both groups took surveys while they were in the hospital and again one and two months after they got home. The research team looked at patients’ health records to see who returned to the hospital within two months after going home.
Patients, caregivers, advocacy groups, and doctors helped design the study.
What were the limits of the study?
Peer coaches couldn’t reach 40 percent of patients in the program because patients didn’t answer the phone or respond to messages. Results may differ if more patients connect with peer coaches. The study only included patients receiving care from one hospital in Illinois. Results may differ for people in other places.
Future research could look at other ways to support patients after they leave the hospital.
How can people use the results?
Hospitals can use these results when considering ways to support patients recovering at home.
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 |
|
| 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.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
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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 assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot 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 descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Overall, the reviewers found the report to be commendable, well organized, and clearly written, requiring only minor revisions.
- Reviewers noted that the lack of fidelity testing of the intervention led to a number of participants not receiving the complete study intervention. The researchers responded that they designed the study with the constraints of routine clinical practice in mind, taking into consideration some of the challenges likely to occur in implementing such an intervention in clinical settings. However, they also agreed that future efforts should have greater emphasis on early fidelity testing to identify potential barriers to intervention implementation.
- A reviewer commented that lack of oversight of telephone coaches allowed too many participants to not receive the intervention. The researchers noted that members of patient advocacy organizations performed the telephone coaching rather than study personnel or hospital staff. The researchers agreed that real-time monitoring and feedback during the intervention could have been helpful. They also added this point to the discussion.