Reducing Preventable Hospitalizations With Two Models of Transitional Care

PURPOSE: Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of health care through temporary follow-up after hospital discharge. This study describes the approaches and outcomes of two distinct transitional care programs serving different populations: one is provided by master's-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPCs). Existing research has shown that transitional care programs with intensive follow-up reduce hospitalizations, emergency department (ED) visits, and costs. Few studies, however, have included side-by-side descriptions of the efficacy of transitional care programs varying by healthcare providers or program focus. DESIGN: This is a retrospective cohort study comparing the number of ED visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included differences in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program (September 2014 to December 2014) were analyzed (n = 98). The average age of participants was 69 years and 65% were female. Data were collected from patients from the PPC program from September 2014 to April 2015 (n = 71). Thirty participants died within 120 days after the intervention and were excluded; the remaining 41 were included in the analysis. Participants had an average age of 81 years and 63% were female. METHODS: For the CNS program, a secondary analysis of existing data was performed. For the PPC program, a review of patient charts was done to collect data on encounters. A Wilcoxon matched-pairs signed-rank test was performed to test for significance. FINDINGS: Patients in the CNS intervention had significantly fewer ED visits (p < .005) and hospitalizations (p < .005) in the 4 months after the intervention than in the 4 months before the intervention. Patients in the PPC program had a nonsignificant reduction in ED visits (p = .327) and a significant reduction in hospitalizations postintervention (p = .03). CONCLUSIONS: Both transitional programs have value in decreasing rehospitalizations. The CNS intervention also significantly reduced ED visits for their target population. Further study with randomized controlled trials is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed. CLINICAL RELEVANCE: Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.