Transitional care patient 'coaches' cut hospital readmissions

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Programs designed to help older patients transition from the hospital to home cuts down on readmissions, according to new studies published in the Archives of Internal Medicine, a Journal of the American of Medical Association.

Typically, 20 to 25 percent of patients age 65 and older are readmitted after 30 days, according to a press release. However, with intervention, a visiting coach can help cut the rate of readmissions.

Researchers at Quality Partners of Rhode Island, Providence looked at 1,888 patients. When a coach visited the patient in the hospital, the home, and followed up with two telephone calls, researchers found that the odds of readmission after care intervention were significantly lower (12.8 percent readmission rate), compared to those without coaches (20 percent).

"The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings," said the authors in the press release.

In another article also published in the journal, researchers at Baylor Health Care System in Dallas found that intervention by an advanced practice nurse and at least eight post-discharge calls cut readmissions of elderly health failure patients by 48 percent.

"[H]owever, the intervention had little effect on hospital length of stay or total 60-day direct costs for the center compared to other hospitals in the Baylor system," stated the press release.

Similarly, a recent University of California, San Francisco, study found that a transition-to-home program cut hospital readmissions in heart patients by 30 percent.

Thomas Jefferson University Hospital in Philadelphia is also targeting heart failure patients by using patient "navigators" to help transition care, reports The Philadelphia Inquirer.

"This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals," said the Baylor authors in the press release. 

To learn more:
- read the press release
- read the Philadelphia Inquirer article
- here's the journal article abstract
- here's the journal editorial abstract

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