Robyn L Reese1,2, Sherry A Clement3,4, Sohera Syeda4, Chelsea E Hawley2,5, Jeffrey S Gosian2,6, Shubing Cai7,8, Laury L Jensen9,10, Amy J H Kind9,10, Jane A Driver2,6,11. 1. University of New England College of Osteopathic Medicine, Biddeford, Maine. 2. Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts. 3. Department of Nursing, VA Boston Healthcare System, Boston, Massachusetts. 4. Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts. 5. Department of Pharmacy, VA Boston Healthcare System, Boston, Massachusetts. 6. Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts. 7. Department of Public Health Services, University of Rochester, Rochester, New York. 8. Geriatrics and Extended Care Data and Analyses Center, Canandaigua VA Medical Center, Canandaigua, New York. 9. Geriatric Research Education and Clinical Center, William S. Middleton VA Hospital, Madison, Wisconsin. 10. Division of Geriatrics, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. 11. Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
Abstract
OBJECTIVES: Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. DESIGN: We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. SETTING: The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. PARTICIPANTS: Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. MEASUREMENTS: A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. RESULTS: Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). CONCLUSION: The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
OBJECTIVES:Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. DESIGN: We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. SETTING: The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. PARTICIPANTS: Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. MEASUREMENTS: A total of 43 (15.8%) C-TraCparticipants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. RESULTS:Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). CONCLUSION: The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraCpatient than per controls, leading the medical center to sustain and expand the program. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
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