Project Summary

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

After a hospital stay, African-American and Hispanic/Latino older adults are more likely to return to the hospital than other older adults. Having support after a hospital stay may help older patients recover and avoid unplanned return visits to the hospital.

In this study, the research team is comparing three ways to support African-American and Hispanic/Latino older adults who are going home after a hospital stay for a chronic condition such as heart disease or diabetes:  

  • Care Transitions Intervention, or CTI. In CTI, a trained coach helps the patient and their caregiver come up with a plan to go home from the hospital safely. Plans address topics such as how to manage medicines and follow up with doctors. After the patient leaves the hospital, coaches help them carry out the plan at home by phone.
  • CTI plus peer support. Patients receive CTI plus two months of counseling with a trained peer mentor after the patient leaves the hospital. Mentors use motivational interviewing, a counseling approach that helps people explore, get ready for, and commit to change. Mentors model positive health behaviors and help patients take an active role in managing their health.
  • Usual care. Patients receive the hospital’s usual help to return home from the hospital. Usual care may include guidance on taking medicines, a list of community resources, or help scheduling home visits.

Who can this research help?

Results may help hospital administrators when considering ways to support older patients when they are going home from the hospital.

What is the research team doing?

The research team is enrolling 402 African-American and Hispanic/Latino older adults who are going home from a hospital stay for a chronic condition from one of three hospitals in Florida. The team is assigning patients by chance to receive CTI, CTI plus peer support, or usual care.

The research team is reviewing patients’ health records to see if patients return to the hospital one, three, and six months after going home. At the start of the study and again one, three, and six months later, the team is surveying patients about:

  • How well hospital staff helped them plan for returning home and performing self-care activities at home
  • Their confidence in managing their chronic health problems
  • Their quality of life
  • Health outcomes such as ability to function, pain, and well-being
  • How well they manage their medicines
  • How satisfied they were with their care

To learn about experiences with the CTI and peer support programs, the research team is also interviewing 48 patients and 24 caregivers.

Patients, caregivers, doctors, nurses, social workers, and advocacy organizations are helping to plan and conduct this study.

Research methods at a glance

Design Element Description
Design Randomized controlled trial
Population 402 African-American and Hispanic/Latino adults ages 60 and older who have a chronic physical illness and are being discharged from the hospital with no planned readmissions
  • CTI
  • CTI plus peer support
  • Usual care

Primary: unplanned all-cause hospital readmissions

Secondary: emergency room visits, discharge planning, self-efficacy in managing chronic disease, quality of life, functional status, mortality, medication management, care satisfaction

Timeframe Timeframe Length of follow-up for collecting data on primary outcomes. View Glossary 6-month follow-up for primary outcome

Conflict of Interest Disclosures

Project Information

Kyaien O. Conner, PhD, MPH, LSW
University of South Florida
Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization

Key Dates

January 2020
April 2025

Study Registration Information


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: April 29, 2024