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The Care Transitions Innovation (C-TraIn) for Socioeconomically Disadvantaged Adults: Results of a Cluster Randomized Controlled Trial

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Abstract

Background

Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions.

Objective

To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality.

Design

Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon.

Participants

Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance.

Intervention

Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement.

Measurements

Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded.

Results

There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30–3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p = 0.02).

Conclusions

C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.

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ACKNOWLEDGMENTS

This work was funded by Oregon Health & Science University, which had no role in the study design or interpretation of results. Funding (Appendix D 15) included evaluation funds, salary for nurse and pharmacy care, and payment to community partners for primary care for uninsured patients who lacked a usual source of care.4

Dr. Kansagara is funded by the Department of Veterans Affairs. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the US government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs.

Results described in this manuscript were presented at the Northwest Regional SGIM meeting in February 2013.

The authors would like to thank members of the C-TraIn Implementation and Research Team who contributed to the work described in this manuscript, including:

• Transitional Care Nurses: Stephanie Peña, Stacey Moultrie

• Pharmacy: Jackie Sharpe, Julie Kidd, Katie Foster, Daniel Kennedy

• Outpatient clinics: Kristy Butler, Lorri Aldridge, Paige Perry, Katie Bensching, Nic Granum, Carol Weber, Amanda Luocks, Billie Kay Stafford, Sandy Anderson, Rachel Solotaroff, Glory Coates, Ivan Wong, Ann Turner

• Clinical Informatics: Anita Murrin

• Hospital Administration: Char Riley, Peter Rapp, Marcha Hunt, Debbie Lamberger, Mayla Gant, Kippi Coffey, Desember Brucker, Jennifer Norquist

• Research Staff and Support: Chad Johnson, Chris Toomey, Christiane Winters, Katelynne Gardner, Sherry Kim, Russell Voth

• Advisors: Cynthia Morris, K. John McConnell, Christina Nicolaidis

Conflict of Interest

The authors declare that they do not have a conflict of interest.

IRB Approval

This study was approved by OHSU’s IRB (eIRB 6208). The full protocol can be accessed upon request to: Honora Englander, MD, englandh@ohsu.edu

Author information

Authors and Affiliations

  1. Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, BTE 119, Portland, OR, 97239, USA

    Honora Englander MD & Devan Kansagara MD, MCR

  2. Old Town Clinic, Central City Concern, Portland, OR, USA

    Honora Englander MD

  3. Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA

    Leann Michaels BS

  4. Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, USA

    Benjamin Chan MS

  5. Department of Medicine, Veterans Affairs Medical Center, Portland, OR, USA

    Devan Kansagara MD, MCR

Authors
  1. Honora Englander MD
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  2. Leann Michaels BS
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  3. Benjamin Chan MS
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  4. Devan Kansagara MD, MCR
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Corresponding author

Correspondence to Honora Englander MD.

Additional information

Clinical Trials: This manuscript was registered with clinical trials.gov (NCT01906645)

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Englander, H., Michaels, L., Chan, B. et al. The Care Transitions Innovation (C-TraIn) for Socioeconomically Disadvantaged Adults: Results of a Cluster Randomized Controlled Trial. J GEN INTERN MED 29, 1460–1467 (2014). https://doi.org/10.1007/s11606-014-2903-0

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  • DOI: https://doi.org/10.1007/s11606-014-2903-0

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