Results Summary
What was the research about?
Before patients leave the emergency room, or ER, hospital staff give instructions on how to care for their illness or injury at home. These instructions include getting follow-up care from their regular doctors. For older adults with long-term health issues, follow-up care is important so patients don’t need to return to the ER.
In this study, the research team tested the use of coaches for patients with Medicare insurance who had recently gone home after a visit to the ER. Coaches were from two Area Agencies on Aging, which offer programs and services that help older adults live on their own. Coaches helped patients
- Schedule follow-up doctor appointments
- Learn to identify and respond to signs of their health getting worse
- Review concerns and instructions for taking medicines
- Talk about care goals with their doctors
- Arrange for services such as meal delivery and rides to doctor visits
The research team compared patients who worked with these coaches with patients who received usual care from the ER. The team looked at quality of life, the number of times patients had to return to the ER or hospital for care, and the number of times patients went to their regular doctors after their ER visits.
What were the results?
Patients who worked with coaches and those who didn’t had similar
- Ratings of quality of life
- Numbers of times they had to return to the ER or hospital
- Numbers of visits with their regular doctors
Compared with patients who didn’t work with a coach, patients who worked with a coach were less likely to have a hospital stay if they did return to the ER.
Who was in the study?
The study included 1,322 patients getting care from two ERs in Florida. Of these, 48 percent were black, 48 percent were white, and 4 percent were other races. The average age was 72. All patients in the study had Medicare insurance. Most patients had more than one long-term health issue.
What did the research team do?
The research team assigned patients by chance to receive either 30 days of support from a health coach or the usual care patients get when leaving the ER. The health coaches met with patients once in person 24 to 72 hours after patients went home from the ER and up to three times by phone as needed during the rest of the study.
Patients who got usual care received standard instructions when going home from the ER. These instructions included how to care for their illness or injury at home and the importance of scheduling a visit with their regular doctors.
Patients, caregivers, staff from the Area Agency on Aging, doctors, and hospital managers helped the team design the study and interpret results.
What were the limits of the study?
Of the patients who received coaching, only 60 percent met with a coach during the study. Results may have been different if more patients had worked with the coaches after going home from the ER.
How can people use the results?
Hospitals can use these results when considering how to help patients after they go home from the ER.
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 |
|
| 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.
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 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:
- Reviewers expressed concern about the overinterpretation of findings based on a large number of comparisons. Since statistical comparisons were not adjusted for multiple-hypothesis testing, the researchers revised the text to emphasize that outcomes based on multiple comparisons should be interpreted with caution. They also emphasized against overinterpreting marginally significant findings.
- Given that the tested intervention did not seem to be effective, reviewers asked for insights on why the intervention did not work as hoped. The researchers added comments from patient participants and providers to their report. The researchers also noted that the increase in self-reported patient anxiety associated with the coaching intervention was not a surprise to patient stakeholders. The researchers noted that extra attention may have sensitized patients to their health condition and motivated them to use more healthcare services.