Professional Abstract

Objective

To test the effectiveness of a patient coaching intervention, compared with usual post-emergency-department (ED) care, in improving quality of life and reducing readmissions for Medicare beneficiaries with chronic illness after discharge from the ED

Study Design

Design Elements	Description
Design	Randomized controlled trial
Population	1,322 Medicare beneficiaries with chronic illness recruited from 2 EDs
Interventions/ Comparators	ED-to-home coaching Usual post-ED care
Outcomes	Primary: patient-reported quality of life as measured by physical function, perceived availability of helpful information or advice, anxiety, ED readmissions, hospitalizations, preventable hospitalizations, preventable ED readmissions Secondary: number of visits with a primary care physician in an outpatient setting
Timeframe	31- to 60-day follow-up for primary outcomes

This randomized controlled trial tested the effectiveness of a patient coaching intervention in improving quality of life and reducing readmissions for Medicare beneficiaries with chronic illness after discharge from the ED compared with usual care.

Researchers recruited 1,322 patients receiving care from two EDs in Florida. Of these, 48% were black, 48% were white, and 4% were other races. The average age was 72. Most patients had multiple chronic conditions.

Researchers randomized patients to receive either ED-to-home coaching or usual post-ED care. Coaches received training in the ED-to-home coaching program and certification in community health work. They worked at two Area Agencies on Aging that provide programs and services to help older adults live on their own. Coaching consisted of one home visit that took place 24 to 72 hours after ED discharge and up to three follow-up phone calls. Coaches helped patients schedule and attend a follow-up doctor visit, recognize and respond to signs and symptoms of worsening disease, review and address concerns about medications, and communicate with healthcare providers. In addition, coaches helped patients access meal assistance programs and transportation to post-ED doctor visits as needed. Coaches documented all interactions and services that patients used, including patients’ self-defined health goals.

In usual care, patients received standard discharge instructions from the ED, which were directions on home care and written and verbal advice to follow-up with their personal doctors.

Researchers surveyed patients in person at baseline and again by phone 30 to 60 days after discharge to assess quality of life using PROMIS® measures. To assess ED visits, hospitalizations, and outpatient visits, researchers used Medicare claims data.

Patients, caregivers, Area Agency on Aging staff, physicians, and health system managers helped researchers design the study and interpret results.

Results

Overall, patients receiving ED-to-home coaching versus usual care did not differ significantly in patients’ quality of life as measured by patient-reported physical function, perceived availability of helpful information or advice, and anxiety. Patients also did not differ in overall ED readmissions, ED readmissions or hospitalizations where primary care may have prevented the need for another ED visit or hospitalization, overall hospitalizations, or number of visits with primary care physicians.

Compared with patients who received usual care, patients who received ED-to-home coaching were less likely to experience hospital admission if they returned to the ED (p<0.01).

Limitations

Of the patients randomized to the intervention, only 60% met with a coach. Results may have been different had more patients worked with the trained coaches after discharge from the ED.

Conclusions and Relevance

Coaching support, compared with usual care, did not improve quality of life or reduce ED visits or hospitalizations for patients with Medicare discharged from the ED.

Future Research Needs

Future research can explore different methods of improving quality of life and reducing ED and hospital readmissions for patients discharged from the ED.