Unplanned hospital readmissions are extremely costly to patients and the healthcare system. Being readmitted to the hospital also leads to increased risk of health complications, including infections and impairments in functioning.
Hospital readmissions are particularly common among older adults. Further, racial/ethnic disparities are evident in readmission rates and are the greatest among African-American and Latino/Hispanic older adults. Effective, sustainable, and culturally appropriate interventions to improve outcomes, reduce unplanned hospital readmissions, and reduce health disparities are urgently needed.
This randomized controlled trial will evaluate the effectiveness of a novel transitional care strategy designed to avoid unplanned hospital readmissions and improve patient health outcomes in a racially/ethnically diverse sample of older adults who have been admitted to the hospital because of a chronic health condition. Transitional care strategies are interventions that begin prior to hospital discharge with the goal of ensuring the safe and effective transition of patients from the hospital setting to the community.
Of all the transitional care interventions tested, Eric Coleman’s Care Transitions Intervention (CTI) has been identified as the strategy most successfully implemented and evaluated in multiple settings and systems of care. CTI is a nonclinical coaching strategy that occurs in the hospital, home, and via telephone for 28 days post-discharge. CTI has been shown to reduce hospital readmissions for non-Hispanic white older adults; however, its effects have not been as strong for minority older adults in some studies, and research trials have not recruited a sufficient number of racial/ethnic minorities to examine outcomes by race or ethnicity. Thus, it is unknown whether CTI is effective for racial/ethnic minority older adults who suffer disproportionately high readmission rates.
Further, studies of transitions interventions suggest that older adult and racial/ethnic minority patients require additional assistance and support during transitions in care. To address this gap, the project team proposes to add peer support (PS) to the CTI to measure whether this enhances its effectiveness among high-risk populations of racial/ethnic minority older adults. The team believes the addition of peer support will enhance and maximize the benefit of the CTI and increase its cultural sensitivity and future sustainability.
The three-arm trial is designed to evaluate the Care Transitions Intervention (CTI), and CTI with PS, compared to usual care (UC), on unplanned hospital readmissions occurring within six months (assessed at 30 days, 90 days, and six months) and secondary health system (i.e., ED visits). The trial will measure patient-centered outcomes (i.e., self-efficacy managing chronic disease, quality of life, functional status, and mortality) among 400 hospitalized African-American and Latino/Hispanic older adults (age 60 or older) who have a chronic physical illness and are being discharged from the hospital back to the community. The team will also maximize the use of this uniquely diverse sample to explore other factors that may impact intervention effects. The team will further conduct semi-structured interviews with patients and caregivers to explore the benefits of adding PS to the CTI to impact disparities.
Other Clinical Interventions
Other Health Services Interventions
Training and Education Interventions
Individuals with Multiple Chronic/co-morbid Conditions
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.