Care transition management and patient outcomes in hospitalized Medicare beneficiaries.

OBJECTIVES: To assess whether discharging hospitals' self-reported care transition activities (CTAs) were associated with transitional care management (TCM) claims following discharge to the community and whether CTAs and TCM were associated with better patient outcomes. STUDY DESIGN: Cross-sectional study of 424,115 hospitalized Medicare fee-for-service beneficiaries 66 years and older who were discharged to the community in 2017 and attributed to 659 hospitals in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate, 46.5%). Of these beneficiaries, 76,156 were categorized into a Hospital Readmissions Reduction Program (HRRP) cohort based on admission principal diagnoses. METHODS: Using logistic regression, we examined the association between survey-based hospital-reported CTAs and an attributed beneficiary's TCM claim. We assessed the associations between hospital CTAs and TCM and beneficiary spending, utilization, and mortality in linear (continuous outcomes) and logistic (binary outcomes) regressions. RESULTS: Beneficiaries attributed to hospitals reporting high (top tertile vs bottom tertile) CTA had a higher probability of TCM after discharge by 3 percentage points. TCM was associated with lower 90-day episode spending (-$2803; P < .001) and improved quality (-28.7 30-day readmissions/1000 beneficiaries; P < .001; -29.7 deaths/1000 beneficiaries; P < .001), and greater use of evaluation and management visits (491/1000 beneficiaries; P = .001). Billing for TCM was associated with significantly lower spending, emergency department visits, hospitalizations, readmissions, and 90-day mortality in the HRRP cohort. Significant utilization reductions were estimated for beneficiaries attributed to high-CTA hospitals. CONCLUSIONS: Beyond recent increases in provider TCM compensation and relaxed billing restrictions, hospitals should be encouraged to increase CTA and to enhance care transitions to improve patient outcomes and lower spending.

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.

PRADOC: A Multicenter Randomized Controlled Trial to Assess the Efficiency of PRADO-IC, a Nationwide Pragmatic Transition Care Management Plan for Hospitalized Patients With Heart Failure in France.

BACKGROUND: The PRADO-IC (Programme de Retour à Domicile après une Insuffisance Cardiaque) is a transition care program designed to improve the coordination of care between hospital and home that was generalized in France in 2014. The PRADO-IC consists of an administrative assistant who visits patients during hospitalization to schedule follow-up visits. The aim of the present study was to evaluate the PRADO-IC program based on the hypotheses provided by health authorities. METHODS AND RESULTS: The PRADOC study is a multicenter, controlled, randomized, open-label, mixed-method trial of the transition program PRADO-IC versus usual management in patients hospitalized with heart failure (standard of care group; NCT03396081). A total of 404 patients were recruited between April 2018 and May 2021. The mean patient age was 75 years (±12 years) in both groups. The 2 groups were well balanced regarding severity indices. At discharge, patients homogeneously received the recommended drugs. There was no difference between groups regarding hospitalizations for acute heart failure at 1 year, with 24.60% in the standard of care group and 25.40% in the PRADO-IC group during the year following the index hospitalization (hazard ratio, 1.04 [95% CI, 0.69-1.56]; P=0.85) or cardiovascular mortality (hazard ratio, 0.67 [95% CI, 0.34-1.31]; P=0.24). CONCLUSIONS: The PRADO-IC has not significantly improved clinical outcomes, though a trend toward reduced cardiovascular mortality is evident. These results will help in understanding how transitional care programs remain to be integrated in pathways of current patients, including telemonitoring, and to better tailor individualized approaches. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03396081.

Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations.

BACKGROUND: The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE: To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN: Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS: Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH: Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS: We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS: Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.

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.

Pilot Process Evaluation of the Supporting Older Adults at Risk Model: A RE-AIM Approach.

ABSTRACT: Despite evidence supporting transitional care models, hospitals report challenges implementing and sustaining them. The Discharge to Assess (D2A) Model is an innovative solution to this problem but required translation from a national health system context to an U.S.-based context. We translated the central tenets of the D2A model to establish the Supporting Older Adults at Risk (SOAR) Model, which unfolds in three phases: Prepare, Transition, and Support. The purpose of this project was to conduct a process evaluation of the SOAR Model in practice using the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Forty patients completed all SOAR Model components for a Reach of 21%. Patients averaged 80 years of age, 53% were female, and 64% Black/AA. SOAR significantly improved discharge before noon, time to first home visit, and use of the in-house pharmacy. SOAR also improved length of hospital stay, emergency department visits, and readmissions. Twenty-one of the 26 Implementation measures unfolded with 75% or greater fidelity. Sixteen of the 24 Adoption measures unfolded with 75% or greater fidelity. COVID-19 limited Maintenance. Given the model unfolds across settings over time, requiring adoption from interprofessional team members, patients, and families, future work should focus on improving reach and adoption.

A Clinical Pharmacist-Led Transitions of Care Program for Veterans with Two Planned Care Transitions (Hospital to Skilled Care and Skilled Care to Home) amid the COVID-19 Pandemic.

Transitional care teams have been shown to improve patient safety. We describe a novel transitional care team with a clinical pharmacist as team leader initiated amid the COVID-19 pandemic. The program focused on Veterans with 2 planned transitions of care: hospital to skilled nursing facility (SNF) and from SNF to home. Ninety older Veterans were enrolled, and 79 medication errors and 80 appointment errors were identified. We conclude that a pharmacist-led program can improve safety in patients with 2 planned transitions of care.

Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program.

BACKGROUND: Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC. METHODS: Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). RESULTS: We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. CONCLUSIONS: HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

A Delphi Study to Construct an Index of Practice for Community Nurses Providing Transitional Home Care for Patients with Chronic Diseases.

Community nurses play a key role in providing continuous home care for patients with chronic diseases. However, a perfect system of responsibilities and requirements has not yet been formed, and nurses cannot provide high-quality nursing services for home-based patients. We attempted to construct an index of the scope of practice for community nurses providing home-based transitional care for patients with chronic diseases and to guide nurses in playing an active role in transitional care work. From March to May 2023, 14 representative community nurses from the Shanghai Community Health Service Center were selected for group interviews and 2 rounds of Delphi consultation. A total of 14 valid questionnaires were collected. The authority coefficients were 0.94 and 0.93, and the Kendall coefficients were 0.56 and 0.59 for the 2 rounds of expert consultation (P < .05). Finally, an index system, including 6 primary indices (transitional caring provider, patient self-management facilitator, community group intervention organizer, home caregiver supporter, family physician team collaborator and supervisor of home medical equipment use, and medical waste disposal) was constructed for community nurses involved in providing home-based transitional care for patients with chronic diseases. The weight values of the 6 indices were 0.19, 0.17, 0.21, 0.13, 0.14 and 0.16, respectively (CR = 0.035, and the consistency test was passed), and 16 secondary indicators and 42 tertiary indicators were identified. In this Delphi study, an index system that can be used to determine community nurses' roles in providing home-based transitional and continuous care for patients with chronic diseases was successfully established. The index system is considered reliable and easy to use and will provide a meaningful reference for community nurses and policy-makers.

Transitional Care in Patients With Hirschsprung Disease: Those Left Behind.

BACKGROUND: The long-term effects of Hirschsprung disease are clinically variable. An improved understanding of challenges patients may face as adults can help inform transitional care management. OBJECTIVE: To explore the outcomes and transitional care experiences in adult patients with Hirschsprung. DESIGN: Cohort study. SETTING: Single center. PATIENTS: All patients treated for Hirschsprung between 1977 and 2001 (aged older than 18 years at the time of survey distribution in July 2018-2019). Eligible patients were sent validated multidomain surveys and qualitative questions regarding their transitional care. MAIN OUTCOME MEASURES: Status of transitional care, bowel function, and quality-of-life assessment. Qualitative analysis of transitional care experience. RESULTS: Of 139 patients, 20 had received transition care (10 had at least 1 visit but had been discharged and 10 were receiving ongoing follow-up). These patients had inferior bowel function and quality-of-life scores at follow-up. Twenty-three patients (17%) had issues with soiling at the time of discharge, and 7 patients received transitional care. Of these 23 patients, 9 (39%) had a normal Bowel Function Score (17 or more), 5 (22%) had a poor score (less than 12), and 1 had since had a stoma formation. Eighteen patients (13%) had active moderate-severe issues related to bowel function, only 5 had been transitioned, and just 2 remained under ongoing care. Importantly, when these patients were discharged from our pediatric center, at a median age of 14 (interquartile range, 12-16) years, 10 of 17 patients had no perceptible bowel issues, suggesting a worsening of function after discharge. LIMITATIONS: The retrospective design and reliance on clinical notes to gather information on discharge status as well as patient recall of events. CONCLUSIONS: There remains a small but significant proportion of Hirschsprung patients for whom bowel function either remains or becomes a major burden. These results support a need to better stratify patients requiring transitional care and ensure a clear route to care if their status changes after discharge. See Video Abstract . ATENCIN DE TRANSICIN EN PACIENTES CON ENFERMEDAD DE HIRSCHSPRUNG, LOS QUE SE QUEDAN ATRS: ANTECEDENTES:Los efectos a largo plazo de la enfermedad de Hirschsprung son clínicamente variables. Una mejor comprensión de los desafíos que los pacientes pueden enfrentar cuando sean adultos puede ayudar a informar la gestión de la atención de transición.OBJETIVO:Explorar los resultados y las experiencias de atención de transición en pacientes adultos con Hirschsprung.DISEÑO:Estudio de cohorte.AJUSTE:Unico centro.PACIENTES:Todos los pacientes tratados por Hirschsprung 1977-2001 (edad >18 años en el momento de la encuesta, Julio de 2018-2019). A los pacientes elegibles se les enviaron encuestas multidominio validadas, así como preguntas cualitativas sobre su atención de transición.PRINCIPALES MEDIDAS DE RESULTADOS:Estado de la atención de transición, función intestinal y evaluación de la calidad de vida. Análisis cualitativo de la experiencia de cuidados transicionales.RESULTADOS:De 139 pacientes, 20 habían recibido atención de transición (10 tuvieron al menos una visita pero habían sido dados de alta y 10 estaban recibiendo seguimiento continuo). Estos pacientes tenían puntuaciones inferiores de función intestinal y calidad de vida en el seguimiento. Veintitrés (17%) pacientes tuvieron problemas para ensuciarse en el momento del alta y 7 recibieron atención de transición. De estos, 9/23 (39%) tenían una puntuación de función intestinal normal (≥17), 5/23 (22%) tenían una puntuación baja (<12) y un paciente había tenido desde entonces una formación de estoma. Dieciocho (13%) pacientes tenían problemas activos de moderados a graves relacionados con la función intestinal, solo cinco habían realizado la transición y solo 2 permanecían bajo atención continua. Es importante destacar que cuando estos pacientes fueron dados de alta de nuestro centro pediátrico, a una edad promedio de 14 [RIQ 12-16] años, 10/17 no tenían problemas intestinales perceptibles, lo que sugiere un empeoramiento de la función después del alta.LIMITACIONES:El diseño retrospectivo y la dependencia de notas clínicas para recopilar información sobre el estado del alta, así como el recuerdo de los eventos por parte del paciente.CONCLUSIÓN:Sigue existiendo una proporción pequeña pero significativa de pacientes con Hirschsprung para quienes la función intestinal permanece o se convierte en una carga importante. Estos resultados respaldan la necesidad de estratificar mejor a los pacientes que requieren atención de transición y garantizar una ruta clara hacia la atención si su estado cambia después del alta. ( Traducción-Dr. Yesenia Rojas-Khalil ).

Transitional Care Navigation.

OBJECTIVES: This manuscript aims to provide an extensive review of the literature, synthesize findings, and present substantial insights on the current state of transitional care navigation. Additionally, the existing models of care, pertaining to the concept and approach to transitional care navigation, will be highlighted. METHODS: An extensive search was conducted though using multiple search engines, topic-specific key terminology, eligibility of studies, as well as a limitation to only literature of existing relevance. Integrity of the evidence was established through a literature review matrix source document. A synthesis of nursing literature from organizations and professional publications was used to generate a comparison among various sources of evidence for this manuscript. Primary evidence sources consisted of peer-reviewed journals and publications from professional organizations such as the AHRQ, Academic Search Premier, CINAHL Plus with Full Text, and the Talbot research library. RESULTS: A total of five systematic reviews (four with meta-analysis) published between 2016 and 2022 and conducted in several countries (Brazil, Korea, Singapore, and the US) were included in this review. A combined total of 105 studies were included in the systematic reviews with 53 studies included in meta-analyses. The review of the systematic reviews identified three overarching themes: care coordination, care transition, and patient navigation. Care coordination was associated with an increase in care quality rating, increased the health-related quality of life in newly diagnosed patients, reduced hospitalization rates, reduced emergency department visits, timeliness in care, and increased appropriateness of healthcare utilization. Transitional care interventions resulted to reduced average number of admissions in the intervention (I) group vs control (C) (I = 0.75, C = 1.02) 180 days after a 60-day intervention, reduced readmissions at 6 months, and reduced average number of visits 180 days after 60-day intervention (I = 2.79, C = 3.60). Nurse navigators significantly improved the timeliness of care from cancer screening to first-course treatment visit (MD = 20.42, CI = 8.74 to 32.10, P = .001). CONCLUSION: The care of the cancer patient entails treatments, therapies, and follow-up care outside of the hospital setting. These transitions can be challenging as they require coordination and collaboration among various health care sites. The attributes of transitional care navigation overlap with care coordination, care transition, and patient navigation. There is an opportunity to formally develop a transitional care navigation model to effectively addresses the challenges in care transitions for patient including barriers to health professional exchange of information or communication across care settings and the complexity of coordination between care settings. The transitional care navigation and clinic model developed at a free-standing NCI-designated comprehensive cancer center is a multidisciplinary approach created to close the gaps in care from hospital to home. IMPLICATIONS FOR NURSING PRACTICE: A transitional care navigation model aims to transform the existing perspectives and viewpoints of hospital discharge and transition of care to home or post-acute care settings as two solitary processes to that of a collective approach to care. The model supports provides an integrated continuum of quality, comprehensive care that supports patient compliance with treatment regimens, reinforces patient and caregiver education, and improves health outcomes.

Transitional care strategies at emergency department for elderly patients: A multicentre study in Singapore.

Introduction: Transitional care strategies (TCS) initiated for elderly patients prior to emergency department (ED) discharge are important for ensuring effective transition to other care settings. Such strategies have been shown to reduce avoidable acute admissions. This first nationwide study is targeted at public acute hospital EDs in Singapore, and aims to characterise TCS for ED-discharged elderly patients and understand the experiences of healthcare staff in the delivery of TCS. Method: Seven key informants (KIs), one per ED, completed an online structured questionnaire and semi-structured video conference interview from 8 May to 31 August 2021. The KIs were ED specialists and an ED-trained senior staff nurse who were knowledgeable in geriatric emergency care and had contributed to at least one elder-related TCS. Field notes were compiled, transcribed, anonymised and analysed using thematic analysis. Results: All 7 EDs have TCS as "usual care" available during office hours, at no extra cost to patients. Common components of TCS include screening, evaluation with comprehensive geriatric assessment, health education and follow-up telecare. TCS implementation was facilitated by organisational support in terms of established protocols and communication platforms, training and collaboration of a multidisciplinary team, and caregiver involvement. Obstacles faced include fragmented communication between personnel, limited resources, and poor buy-in from stakeholders. Conclusion: Understanding the heterogeneous characteristics of ED-TCS at various hospitals will aid the development of service typology and identify service opportunities. Provider experiences grouped into themes help to inform future strategies for TCS implementation. More research is needed to evaluate patient outcomes and cost-effectiveness of TCS.

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.

Predictive modeling of service discontinuation in transitional age youth with recent behavioral health service use.

OBJECTIVE: To develop and test predictive models of discontinuation of behavioral health service use within 12 months in transitional age youth with recent behavioral health service use. DATA SOURCES: Administrative claims for Medicaid beneficiaries aged 15-26 years in Connecticut. STUDY DESIGN: We compared the performance of a decision tree, random forest, and gradient boosting machine learning algorithms to logistic regression in predicting service discontinuation within 12 months among beneficiaries using behavioral health services. DATA EXTRACTION: We identified 33,532 transitional age youth with ≥1 claim for a primary behavioral health diagnosis in 2016 and Medicaid enrollment of ≥11 months in 2016 and ≥11 months in 2017. PRINCIPAL FINDINGS: Classification accuracy for identifying youth who discontinued behavioral health service use was highest for gradient boosting (80%, AUC = 0.86), decision tree (79%, AUC = 0.84), and random forest (79%, AUC = 0.86), as compared with logistic regression (71%, AUC = 0.71). CONCLUSIONS: Predictive models based on Medicaid claims can assist in identifying transitional age youth who are at risk of discontinuing from behavioral health care within 12 months, thus allowing for proactive assessment and outreach to promote continuity of care for younger persons who have behavioral health needs.

An integrated model of care utilizing community health workers to promote safe transitions of care.

BACKGROUND/OBJECTIVES: Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost-prohibitive resource needs. Cost-effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs. DESIGN: A cohort study with a pre-post intervention evaluation of the intervention group. SETTING: A 953-bed academic urban safety-net hospital. PARTICIPANTS: Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission. INTERVENTION: Promotion of self-management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self-management education. MEASUREMENTS: Outcome measures were readmissions, ER visits, and PCP establishment. RESULTS: Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z = 9.6, p < 0.001), also observed at 30-day (Z = 5.5, p < 0.001), 3-month (Z = 4.3, p < 0.001), 6-month (Z = 4.0, p = 0.001), and 1-year (Z = 5.4, p < 0.001) post-intervention. There was a significant reduction in the overall number of ER visits (Z = 5.5, p < 0.001), also seen at 3-month (Z = 3.3, p < 0.001), 6-month (Z = 3.0, p < 0.001), and 1-year (Z = 4.0, p < 0.001) intervals. Care with a PCP was established in 86.6% of participants. Utilization costs were significantly lower post-intervention ($11,530,376.39 vs $4,017,493.17, p < 0.001). CONCLUSION: Use of CHWs during transitions of care may be a cost-effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative.

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Trends in telehealth and in-person transitional care management visits during the COVID-19 pandemic.

BACKGROUND/OBJECTIVES: Transitional care management (TCM) visits delivered following hospitalization have been associated with reductions in mortality, readmissions, and total costs; however, uptake remains low. We sought to describe trends in TCM visit delivery during the COVID-19 pandemic. DESIGN: Cross-sectional study of ambulatory electronic health records from December 30, 2019 and January 3, 2021. SETTING: United States. PARTICIPANTS: Forty four thousand six hundred and eighty-one patients receiving transitional care management services. MEASUREMENTS: Weekly rates of in-person and telehealth TCM visits before COVID-19 was declared a national emergency (December 30, 2019 to March 15, 2020), during the initial pandemic period (March 16, 2020 to April 12, 2020) and later period (April 12, 2020 to January 3, 2021). Characteristics of patients receiving in-person and telehealth TCM visits were compared. RESULTS: A total of 44,681 TCM visits occurred during the study period with the majority of patients receiving TCM visits age 65 years and older (68.0%) and female (55.0%) Prior to the COVID-19 pandemic, nearly all TCM visits were conducted in-person. In the initial pandemic, there was an immediate decline in overall TCM visits and a rise in telehealth TCM visits, accounting for 15.4% of TCM visits during this period. In the later pandemic, the average weekly number of TCM visits was 841 and 14.0% were telehealth. During the initial and later pandemic periods, 73.3% and 33.6% of COVID-19-related TCM visits were conducted by telehealth, respectively. Across periods, patterns of telehealth use for TCM visits were similar for younger and older adults. CONCLUSION: The study findings highlight a novel and sustained shift to providing TCM services via telehealth during the COVID-19 pandemic, which may reduce barriers to accessing a high-value service for older adults during a vulnerable transition period. Further investigations comparing outcomes of in-person and telehealth TCM visits are needed to inform innovation in ambulatory post-discharge care.