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.

Final Research Report

View this project's final research report.

Stories and Videos

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.

Conflict of Interest Disclosures

Project Information

Jerry Krishnan, MD, PhD
University of Illinois at Chicago
$2,054,690 *
PATient Navigator to rEduce Readmissions -- The PArTNER Study

Key Dates

May 2013
November 2018

Study Registration Information

Final Research Report

View this project's final research report.

Journal Articles


Has Results
Award Type
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: October 18, 2023