Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial

Abstract

Background: There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.

Objective: Evaluate effects of a transitional care practice (TC) that comprehensively addresses patients' medical and psychosocial needs following hospital discharge.

Design: Pragmatic, randomized comparative effectiveness trial.

Patients: Adults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care.

Interventions: TC intervention included a scheduled post-discharge appointment at the TC practice, where a multidisciplinary team comprehensively assessed patients' medical and psychosocial needs, addressed modifiable barriers, and subsequent linkage to a new primary care source. Routine Care involved assistance scheduling a post-discharge appointment with a primary care provider that often partnered with the hospital where the initial encounter occurred.

Main measures: The primary outcome was a binary indicator of death or additional hospital encounters within 90 days of initial discharge. Secondary outcomes included any additional hospital encounters, and counts of hospital encounters, over 180 days.

Key results: Four hundred ninety patients were randomized to TC intervention and 164 to Routine Care; 34.6% were uninsured, 49.7% had Medicaid, and 57.4% were homeless or lived in a high-poverty area. There was no significant difference between arms in the 90-day probability of death or additional hospital encounters (relative risk [RR] 0.89; 0.91; 95% confidence interval [CI] 0.74-1.13). However, TC patients had 37% and 35% lower probability of any inpatient admission over 90 days (RR 0.63; 95% CI 0.43-0.91) and 180 days (RR 0.65; 95% CI 0.47-0.89), respectively. Over 180 days, TC patients had 42% fewer inpatient admissions (incidence rate ratio 0.58; 95% CI 0.37-0.90).

Conclusions: Among patients randomized to a patient-centered transitional care intervention, there was no significant reduction in 90-day probability of death or additional hospital encounters. However, there were significant decreases in measures of inpatient admissions over 180 days.

Trial registration: clinicaltrials.gov identifier NCT03066492.

Keywords: care transitions; comparative effectiveness; hospital discharge; patient-centered care; randomized trials; underserved populations; vulnerable populations.

Conflict of interest statement

Dr. Schaeffer, Ms. Rogers, and Ms. Teter report employment as health care providers at the Northwestern Medical Group Transitional Care (TC) practice, and Ms. Hurt formerly provided social work services at the Northwestern Medical Group TC practice. All remaining authors declare that they do not have a conflict of interest.

Figures

Figure 1

Trial flow diagram. *Due to reasons such as being discharged from emergency department at an hour when referral team staff were not present, or no order placed for follow-up care following an inpatient admission or observation stay. †Due to reasons such as already having a usual care provider.