TABLE 1.

Overview of 9 Transitional Care Studies in Patient-Centered Outcomes Research Institute’s Transitional Care Portfolio15–20

Study	Institution	Study Design (Unit of Randomization)	Sample Size	Core Function (Purpose) (Example)	Form (Activities) (Example)	Adaptation (Example)	Results for Primary Research Question	Outcomes for the System	Outcomes for Patients
Early Supported Discharge for Improving Functional Outcomes after Stroke (COMPASS) 15	Wake Forest University Health Sciences	Pragmatic cluster randomized RCT (hospital)	6024 adult stroke patients 40 hospitals in North Carolina	Comprehensive assessment (neurological, medical, cognitive, social determinants of health) of patient and caregiver needs, which informs a tailored care plan that is handed to the patient	Timing of assessment and care planning ideally within 14 d of discharge for billing purposes, but can be completed with 30 d to be considered delivered	In addition to care plan, several hospitals provided patients with a blood pressure cuff as most care plans indicated patient needed to control blood pressure. Adaptation not assessed	The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean (±SD) Stroke Impact Scale-16 was 80.6±21.1 in TC vs. 79.9±21.4 in usual care	90 d all-cause readmission; 30 d and readmission, 1 y mortality; 30, 90 d, and 1 y recurrent stroke readmission	Physical function mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls
Comparative Effectiveness of Rehabilitation Services for Survivors of an Acute Ischemic Stroke16	Duke University	Observational (NA)	147,716 adults treated for acute ischemic stroke at 1192 US hospitals	Transition from hospital to continued inpatient care of different rehabilitation intensities (rehabilitation or skilled nursing facility) or to home with different levels of service provision (home health, outpatient therapy, or no further services except clinic-based medical care)	Continued inpatient care required to have a 3 d stay but type and dose of therapy in any of the comparison groups could vary	No adaptations assessed	Stroke patients experience 3+ transitions from acute hospital care and 3 and 12 mo outcomes were most favorable for patients who received inpatient rehabilitation care	Days at home and health care utilization (days living at home and no longer receiving stroke-related services; timeliness of community-based care; 3 and 12 mo rehospitalizations; nursing home institutionalization)	Disability, quality of life, mortality
Improving Transition from Acute to Post-Acute Care following Traumatic Brain Injury—the BRITE Study	University of Washington	Pragmatic RCT (patient)	Enrollment goal: 900 individuals with moderate to severe traumatic brain injury (TBI) discharged from inpatient rehabilitation and 540 caregivers across 6 sites across the United States (WA, IN, OH, NY, PA, TX)	Patient and caregiver participants have contact with a TBI Care Manager across the first 6 mo postdischarge to identify and address needs, provide care coordination, education and support on TBI, and transition to appropriate support at 6 mo	TBI Care Manager contacts the patient and caregiver within 7 d postdischarge, weekly for 4 wk, then bimonthly, then monthly for up to 12 contacts	Contacts number and timing is flexible depending on patient and caregiver needs	Study is still in-progress, results not yet available	Completing discharge recommendations and health care utilization across first year postdischarge	Patient: participation, health related quality of life, planned outpatient visits, urgent care visits/unplanned hospitalizations. Caregiver: burden, health-related quality of life, satisfaction with roles, time spent in caregiving
Emergency Medicine Palliative Care Access (EMPallA)	NYU Grossman School of Medicine	Pragmatic RCT (patient)	1350 emergency department (ED) patients 50+ years with serious illness at 16 health systems across the United States	Patient receives either nurse-led telephonic case management to facilitate sustainability and scalability in real-world settings or outpatient specialty palliative care; These interventions may improve patient-centered outcomes including quality of life, loneliness, and social isolation, and may reduce strain in informal caregivers. These interventions may also decrease future health care utilization (ie, ED visits and hospital admissions) and increase hospice use in patient participants; This study will help align discussions for patients and providers regarding goals of care, end-of-life wishes, advance directives, pain and symptom management, and community resources	Enrollment ideally will occur in-person for patients who are scheduled for ED discharge or observation status, but can occur within 48 h of discharge	Due to the coronavirus disease of 2019 pandemic, research coordinators were unable to recruit in the ED. Study protocol was adapted to allow for telephonic recruitment. Preliminary adaptation data demonstrates that despite recruitment method (in-person or telephonic) intervention engagement is the same	Study is still in-progress, results not yet available	A product of the dissemination and implementation plan will include a business plan that will accurately lay out the 1, 3, and 5 y return on investment for implementing a nurse-led telephonic case management program for seriously ill patients within an integrated health system and/or health plan. The business plan will include a toolkit that we will make openly accessible to payers and health care systems interested in adapting it for their local health care market	Compare nurse-led telephonic case management to facilitated, outpatient specialty palliative care on: quality of life; health care use in the 6 mo following enrollment; loneliness; and caregiver strain
PATient Navigator to rEduce Readmissions (PArTNER)17	University of Illinois at Chicago	Pragmatic RCT (patient)	1029 adults hospitalized with heart failure, pneumonia, chronic obstructive pulmonary disease, myocardial infarction sickle cell disease crisis	Standardized comprehensive assessment of self-management skills, socioeconomic resources, and access to postacute care. Information used to develop personalized plan (navigator intervention) to support safe hospital-to-home transitions	In-hospital and home visits by community health worker. Peer-to-peer coaching delivered by community-based patient advocacy organizations via phone	Patient preference and feasibility used to define extent and timing of in-hospital and home-based interventions, and number of peer coaching sessions	Results pending	30 and 60 d hospital readmissions	30 and 60 d PROMIS measures of emotional, social, and physical health
The Sickle Cell Trevor Thompson Transition Project (ST3P-UP) Study	Atrium Health	Pragmatic RCT (practice)	537 emerging adults (16−25 y old) with sickle cell disease	Publication in development	Publication in development	No adaptations assessed	Study is in progress; results not yet available	Standardized care for individuals with sickle cell disease across pediatric and adult practices using the 6 core elements of transition	Patient reported outcomes (social support, health related quality of life, patient satisfaction, quality of care received; transition readiness
Relative Patient Benefits of a Hospital-PCMH Collaboration within an ACO to Improve Care Transitions18	Brigham and Women’s Hospital; Massachusetts General Hospital; Partners Health care	Pragmatic RCT (patient)	In press	Inpatient discharge advocate: nurse who communicates with outpatient team to ensure a safe discharge plan and prepares patients for discharge	Hospital 1: 1 NP played role, high degree of quality control, but not enough availability to see all patients; Hospital 2: Attending nurses played role, but restricted to communication with responsible outpatient clinician, less quality control	No adaptations assessed	In press	In press	In press
Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence) 19	University of Kentucky	Observational (NA)	7939 patients at 42 hospitals across nation	22 transitional care strategies	22 transitional care strategies	No adaptations assessed	One group of transitional care strategies—Hospital-based trust, plain language, and coordination—is significantly associated with reduced utilizations and positive patient-reported outcomes	Health care utilization (30 d readmissions, 7 d ED visits)	Patient-reported outcomes (physical health, mental health, daily activities) patient experience
An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use20	University of Florida	RCT (patient)	1101 from 2 hospitals; Intervention group (IG): 557; Usual care (UC): 544	Core functions—IG: patient received DC instructions in ED; 3 follow-up phone calls and 1 home visit by trained health coach within 30 d. UC: patient received DC instructions in ED	Follow-up visits and phone calls from health coach following Coleman TCI protocol+transportation and home delivered meals as needed (IG) vs. usual postdischarge follow-up (UC)	No adaptations	NS differences return ED visits, hospital admissions, outpatient visits; IG had reduced hospital admission in those with return ED visits (OR=0.64)	Return ED visits, hospital admissions, outpatient visits	Return ED visits hospital admission outpatient visits informational support anxiety physical function

ACO indicates accountable care organization; NA, not applicable; NP, nurse practitioner; NS, not significant; NYU, New York University; OR, odds ratio; PCMH, patient-centered medical home; PROMIS, Patient-Reported Outcomes Measurement Information System; RCT, randomized controlled trial; TCI, transitional care intervention.