Background: As health systems shift toward value-based care, strategies to reduce readmissions and improve patient outcomes become increasingly important. Despite extensive research, the combinations of transitional care (TC) strategies associated with best patient-centered outcomes remain uncertain. Methods: Using an observational, prospective cohort study design, Project ACHIEVE sought to determine the association of different combinations of TC strategies with patient-reported and postdischarge health care utilization outcomes. Using purposive sampling, the research team recruited a diverse sample of short-term acute care and critical access hospitals in the United States (N = 42) and analyzed data on eligible Medicare beneficiaries (N = 7,939) discharged from their medical/surgical units. Using both hospital- and patient-reported TC strategy exposure data, the project compared patients “exposed” to each of five overlapping groups of TC strategies to their “control” counterparts. Primary outcomes included 30-day hospital readmissions, 7-day postdischarge emergency department (ED) visits and patient-reported physical and mental health, pain, and participation in daily activities. Results: Participants averaged 72.3 years old (standard deviation =10.1), 53.4% were female, and most were White (78.9%). Patients exposed to one TC group (Hospital-Based Trust, Plain Language, and Coordination) were less likely to have 30-day readmissions (risk ratio [RR], 0.72; 95% confidence interval [CI] = 0.57–0.92, p < 0.001) or 7-day ED visits (RR, 0.72; 95% CI, 0.55–0.93, p < 0.001) and more likely to report excellent physical and mental health, greater participation in daily activities, and less pain (RR ranged from 1.11 to 1.15, p < 0.01). Conclusion: In concert with care coordination activities that bridge the transition from hospital to home, hospitals’ clear communication and fostering of trust with patients were associated with better patient-reported outcomes and reduced health care utilization.
|Number of pages||13|
|Journal||Joint Commission Journal on Quality and Patient Safety|
|State||Published - Jan 2022|
Bibliographical noteFunding Information:
Research reported in this manuscript was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (TC-1403-14049). The statements in this manuscript are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee.
© 2021 The Author(s)
- Care transitions
- Hospital Readmissions
- Patient Communication
ASJC Scopus subject areas
- Leadership and Management