Table 2.
Highlighted Hospital-Based Transitional Care Programs.
| Programs | Strategies | Description/Effectiveness |
|---|---|---|
| Care Transitions Intervention40-43 | Patient engagement Individualized patient record Dedicated transition provider Facilitation of communication to outpatient providers Outreach Medication reconciliation | Focuses on 4 domains of care including self management skills |
| Studied in several settings | ||
| CCT40,43 and RCT41,42 | ||
| Decreased 30-day readmission rates: ARR 4.9%,40 ARR 3.6%,41 and ARR 5.8%43 | ||
| Decreased 90-day readmission rates: ARR 5.8%41 and ARR 21.7%42 | ||
| 30-Day ED visits: ARR 3.2% (NS)40 | ||
| Transitional Care Model44-47 | Patient engagement Individualized patient record Dedicated transition provider Facilitation of communication to outpatient providers Facilitated clinical follow-up Outreach | Nurse-led program studied in geriatric patients, intensive outreach with home and telephone follow-up |
| RCT | ||
| Decreased 90-day readmission rates: ARR 16.8%44 (within 24 weeks), ARR 48.0%,45 and ARR 13%46 (within 6 weeks) | ||
| ED visits (within 24 week): NS44,47 | ||
| Adverse events (postdischarge infection) ARR 16.7% (NS)45 | ||
| Project RED48 | Patient engagement Individualized patient record Dedicated transition provider Facilitation of communication to outpatient provider Multidisciplinary team Outreach Medication reconciliation (predischarge and postdischarge) | Team-based program included pharmacist outreach and medication reconciliation |
| RCT | ||
| Decreased 30-day readmission rates: ARR 5.8% (NS) | ||
| Decreased 30-day ED visits: ARR 8.0% | ||
| Project BOOST49-52 | Patient engagement Multidisciplinary team Outreach Medication reconciliation Risk assessment | Multicenter QI program with mentored implementation |
| CCT49 and pre–post study51 | ||
| Decreased 30-day readmission rates: ARR 2%51 and ARR 5.9%49 |
Abbreviations: ARR, absolute risk reduction; CCT, clinical controlled trial (nonrandomized); ED, emergency department; NS, not significant; QI, quality improvement; RCT, randomized controlled trial; RED, Reengineered Discharge; BOOST, Better Outcomes for Older Adults Through Safe Transitions.