Identification of interventions to improve patient experienced quality of care in transitions between healthcare settings: a scoping review.

BACKGROUND: Transitions in healthcare settings can be a challenge for patients and they express a need for guidance and support to cope with these transitions. The aim of this scoping review was to investigate if interventions can improve patients' experiences when transitioning between healthcare settings. METHODS: This review was conducted following the Johanna Briggs Institute's methods and reported according to the PRISMA-ScR Checklist. Included articles were published and peer-reviewed, and reported qualitative and quantitative findings on patient experiences with interventions when transitioning between healthcare settings. The search was conducted in May 2024 in Medline Ovid, Embase Ovid, and Cinahl. RESULTS: Twenty-three studies were included. Factors extracted from the studies were: author(s), year of publication, country of origin, study design, theoretical methods, population description, intervention, phenomena of interest(s), and key findings. There has been an increase in published studies on the subject in the last few years, and most of the included studies originated from Western countries. Most studies were quantitative, primarily RCTs, and the theoretical methods were thus mainly statistical analysis. The study populations were found to be heterogeneous. The interventions were categorized: care coordinator, program, integrated care, online communication platform, coaching, discharge care plan, and miscellaneous interventions. CONCLUSIONS: Overall, interventions were found to improve the patient experience. Centralization of healthcare has increased the number of transitions, and patients express that the coordination of healthcare transitions can be improved. This review's findings should be used alongside other research on interventions' effect on factors like hospital readmissions and mortality to determine the optimal intervention to implement.

A scoping review of hospital to home transitional care programmes for stroke survivors.

AIM: The study was aimed at exploring the current scope of hospital to home transitional care programmes for stroke survivors. BACKGROUND: Stroke survivors face the dilemma of solving many complex problems that leave survivors at high risk for readmission as they discharge from hospital. The transitional care model has proved to be effective in reducing readmissions and mortality, thereby improving health outcomes and enhancing patient satisfaction for survivors with stroke. DESIGN: A scoping review. METHODS: Conducted in accordance with the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews. DATA SOURCES: A comprehensive search was conducted in nine databases, including PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL, Medline, China Knowledge Net-work, Wanfang Database and China Biomedical Literature Database (SinoMed) from January 2014 to June 2023. RESULTS: Title and abstract screening was performed on 10,171 articles resulting in 287 articles for full-text screening. Full-text screening yielded 49 articles that met inclusion criteria. CONCLUSION: This study identified transitional care programmes for stroke survivors, as well as areas for future consideration to be explored in more depth to help improve transitional care for stroke survivors as they transition from hospital to home. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This study demonstrates that multidisciplinary collaboration becomes an integral part of the transitional care model for stroke survivors, which provides comprehensive and precise medical care to them. REPORTING METHOD: PRISMA checklist for scoping reviews. PATIENT AND PUBLIC CONTRIBUTION: No patient or public contribution was part of this study.

Effects of transitional care interventions on quality of life in people with lung cancer: A systematic review and meta-analysis.

AIM: To identify and appraise the quality of evidence of transitional care interventions on quality of life in lung cancer patients. BACKGROUND: Quality of life is a strong predictor of survival. The transition from hospital to home is a high-risk period for patients' readmission and death, which seriously affect their quality of life. DESIGN: Systematic review and meta-analysis. METHODS: The PubMed, Embase, Cochrane Library, Web of Science and CINAHL databases were searched from inception to 22 October 2022. The primary outcome was quality of life. Statistical analysis was conducted using Review Manager 5.4, results were expressed as standard mean difference (SMD) with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Cochrane risk of bias assessment tool. This study was complied with PRISMA guidelines and previously registered in PROSPERO (CRD42023429464). RESULTS: Fourteen randomized controlled trials were included consisting of a total of 1700 participants, and 12 studies were included in the meta-analysis. It was found that transitional care interventions significantly improved quality of life (SMD = 0.21, 95% CI: 0.02 to 0.40, p = .03) and helped reduce symptoms (SMD = -0.65, 95% CI: -1.13 to -0.18, p = .007) in lung cancer patients, but did not significantly reduce anxiety and depression, and the effect on self-efficacy was unclear. CONCLUSIONS: This study shows that transitional care interventions can improve quality of life and reduce symptoms in patients, and that primarily educational interventions based on symptom management theory appeared to be more effective. But, there was no statistically significant effect on anxiety and depression. RELEVANCE TO CLINICAL PRACTICE: This study provides references for the application of transitional care interventions in the field of lung cancer care, and encourages nurses and physicians to apply transitional care plans to facilitate patients' safe transition from hospital to home. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia.

Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.

Transitional pain services updates and a novel service for the obstetric population.

PURPOSE OF REVIEW: This paper is an update of the publications on Transitional Pain Services and explores the viability of a dedicated transitional pain service for women. RECENT FINDINGS: We address common pain pathologies establishing referral criteria, pathways, and effective strategies to decrease chronification of pain during pregnancy. SUMMARY: This review highlights the importance establishing transitional pain service models at every institution and in particular in obstetric population as pain is normalized by Society during pregnancy.

Transitional care for patients with acute stroke-A priority-setting project.

BACKGROUND: The scope of this priority-setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority-setting methods are time-consuming and require extensive resources. They are therefore not feasible in small-scale research. This article describes a pragmatic priority-setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke. METHODS: A pragmatic priority-setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list. RESULTS: The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories 'patients and caregivers' needs and health literacy', 'health personnel's common understanding', 'information flow between health personnel and patients and caregivers', 'available interventions and follow-up of patients and caregivers', 'interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare' and 'disabilities after stroke'. CONCLUSION: This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke. PATIENT AND PUBLIC CONTRIBUTION: Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures.

BACKGROUND: Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. METHODS AND RESULTS: This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. CONCLUSION: Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio.

BACKGROUND: Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. OBJECTIVE: The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. RESEARCH DESIGN: Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. RESULTS: Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. CONCLUSION: These lessons can help guide future pragmatic studies of care transitions.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers.

BACKGROUND: Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking. AIM: To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs. METHODS: We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis. RESULTS: Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation. CONCLUSION: Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review.

BACKGROUND: Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components' role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes). METHODS: Randomized controlled trials (sample size ≥50 participants per group; intervention period ≥30 days), with geriatric patients were included. Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Central Register of Controlled Trials) were searched from January 1994 to December 2019 published in English or German. A qualitative synthesis of the findings as well as a systematic assessment of the interventions intensities was performed. RESULTS: Three articles met the inclusion criteria. One of the included trials applied all of the nine Transitional Care Model components described by Hirschman and colleagues and obtained a high-intensity level of intervention in the intensities assessment. This and another trial reported reductions in the readmission rate (p < 0.05), but the third trial did not report significant differences between the groups in the longer follow-up period (up to 12 months). CONCLUSIONS: Our findings suggest that high intensity multicomponent and multidisciplinary interventions are likely to be effective reducing readmission rates in geriatric patients, without increasing cost. Components such as type of staffing, assessing and managing symptoms, educating and promoting self-management, maintaining relationships and fostering coordination seem to have an important role in reducing the readmission rate. Research is needed to perform further investigations addressing geriatric patients well above 65 years old, to further understand the importance of individual components of the TCM in this population.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives.

BACKGROUND: Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home. METHODS: We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles. RESULTS: Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs. CONCLUSIONS: It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients. TRIAL REGISTRATION: The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial.

BACKGROUND: While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS: A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS: In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION: This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION: The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

A mapping review of clinical nurse leader and nurse educator transitional care skills and competencies.

BACKGROUND: Little is known about how nurses are prepared to participate or lead teams in conducting safe and effective care transitions, despite being a complex process in which the nurse has an integral role. PURPOSE: To conduct mapping review to identify and synthesize key recommendations regarding curriculum content needed to increase Clinical Nurse Leader and Nurse Educator student knowledge and skills regarding transitional care. METHOD: Guidelines for developing the transitional care nurse role published by national accrediting bodies and certification organizations were reviewed to identify the required competencies. FINDINGS: Components identified included: communication; teamwork and collaboration; education and engagement of patient and family; promoting and support for self-management; and assessing/ managing risks/symptoms. CONCLUSION: Research evidence is needed to support academic preparation of nurses as leaders in care transition. The core transitional components identified can be used to develop competencies to assist training efforts of nurses in practice and educational settings.

Transitional Care Home Visits Among Underserved Patients With Heart Failure.

Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination.

Evidence-Based Secondary Transition Predictors for Physical Therapists Working With High School Students.

PURPOSE: Individuals with disabilities experience poorer postschool outcomes compared with their peers without disabilities. Youth with orthopedic or physical disabilities experience challenges during transition particularly in the areas of education and employment. Physical therapists should continue to become more involved in transition planning and providing services for transition-age students with physical disabilities. The purpose of this article is to clarify the role of physical therapists who work with students who have disabilities, as they transition from high school to postsecondary roles as well as provide the current evidence-based predictors of postschool success and recommended practices to school-based physical therapists who work with these students. SUMMARY OF KEY POINTS: Evidence-based instructional practices for secondary students with disabilities and identified in-school predictors of postschool success for students with disabilities are aligned with effective practices for physical therapists. Additionally, suggestions for involving physical therapists in transition planning and increasing collaboration in providing transition services for students with disabilities are provided. STATEMENT OF CONCLUSIONS: Physical therapists can provide critical expertise for many individuals with disabilities; however, they are not always included effectively in transition planning and services for students with disabilities. RECOMMENDATIONS FOR CLINICAL PRACTICE: Recommendations for practice include ways to involve physical therapists in transition planning and services and increasing collaboration between teachers, physical therapists, and other members of the Individualized Education Program team to provide effective, comprehensive transition services.

Changes in older adults' impairment, activity, participation and wellbeing as measured by the AusTOMs following participation in a Transition Care Program.

INTRODUCTION: Maintaining a continuum of care is vital to ensure adequate health among older adults, particularly during periods of care transitions, when they are vulnerable and at risk of poor health outcomes. The Transition Care Program in Australia is designed to support older adults following the conclusion of a hospital episode. Using the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT), this study aimed to understand how the Transition Care Program impacts an older adult's occupational performance during care transitions. METHODS: Data were collected as a part of usual occupational therapy care from March 2016 to August 2017 from clients admitted to a Gold Coast Health Transition Care Program. Data from 110 clients were analysed on 5 AusTOMs-OT scales: functional walking and mobility, upper limb use, self care, domestic life-home, and community life/recreation/leisure/play. Change data from these scales were analysed using the Wilcoxon Signed Ranks Test. RESULTS: Clients in the Transition Care Program experienced statistically and clinically significant improvements in all AusTOMs-OT scales analysed as well as in each domain of impairment, activity limitation, participation restriction and distress/wellbeing. CONCLUSION: These results are meaningful for clients, occupational therapists and Australian Transition Care Programs. Clients demonstrated progress towards their goals, indicating maintenance or improvements in their occupational performance, confirming for occupational therapists that the provision of services is promoting goal achievement and leading to improved occupational performance. The study also highlighted the benefits for the use of outcome measures such as the AusTOMs-OT to quantify and validate client change.

The Care Transitions Measure-3 Is Only Weakly Associated with Post-discharge Outcomes: a Retrospective Cohort Study in 48,384 Albertans.

BACKGROUND: The National Quality Forum endorsed a 3-item Care Transitions Measure (CTM-3), part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, for evaluating hospital care transitions performance. OBJECTIVE: To explore whether CTM-3 scores are a suitable proxy for quality of transitional care. DESIGN: Retrospective cohort study. PARTICIPANTS: A random sample of 48,384 adults discharged from medical or surgical wards in all 113 acute care hospitals in Alberta, Canada, between April 2011 and March 2016. MAIN MEASURES: CTM-3 scores and their associations with all-cause emergency department (ED) visits or non-elective readmissions at 30 days, 3 months, and 12 months anywhere in the province. RESULTS: CTM-3 scores were significantly lower (all p < 0.01) for females, older patients, those discharged from medical wards or teaching hospitals, and those with longer length of stay, higher Charlson scores, prior ED visits/hospitalizations, or who did not return to independent living after discharge. CTM-3 scores were not significantly associated with outcomes at 30 days (mean score 77.5 in those who subsequently had an ED visit/readmission vs. 77.9 in those who did not, p = 0.13, aOR 0.99, 95% CI 0.99-0.99). Although CTM-3 scores were significantly lower in patients who subsequently had ED visit/readmission at 3 months (77.5 vs. 78.5) and 12 months (77.6 vs. 79.5), the magnitude of risk was small: for every 10 point decrease in the CTM-3 score, the risk of ED visit/readmission was 2.6% higher (aOR 1.03, 95% CI 1.01-1.05) at 3 months and 4.0% higher (aOR 1.04, 95% CI 1.01-1.08) at 12 months. CONCLUSIONS: The CTM-3 score is influenced by baseline patient and hospital factors, is not associated with 30-day post-discharge outcomes, and is only weakly associated with 3- and 12-month outcomes. These findings suggest that the CTM-3 score is not a good performance measure for the quality of transitional care.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial.

BACKGROUND: Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings. OBJECTIVE: To evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission. DESIGN: A non-blinded, pragmatic randomized controlled trial ( Clinicaltrials.gov : NCT02763202) conducted at two hospitals in Charlotte, North Carolina. PATIENTS: A total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions. INTERVENTION: Random allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941). MAIN MEASURE: Thirty-day, unplanned, inpatient, or observation readmission rate. KEY RESULTS: The 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02). CONCLUSIONS: An intervention inclusive of contemporary recommendations does not reduce a high-risk population's 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions. TRIAL REGISTRY: ClinicalTrials.gov ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202.