Researchers at the Institute for Public Health and Medicine at Northwestern recently published a study in the Journal of General Internal Medicine that reported on a pragmatic, randomized comparative effectiveness trial that studied that effects of a transitional care practice for vulnerable populations.
Beyond 30 days post-discharge and in vulnerable populations, there is limited experimental evidence on transitional care interventions. Care transitions following hospital discharge are often characterized by lack of timely follow-up, failure to address psychosocial factors related to hospitalization, and poor communication of care plans to patients and follow-up providers. These issues are particularly salient for vulnerable populations such as patients of low socioeconomic status (SES), who face challenges such as understanding and executing discharge plans, competing socioeconomic needs, and poor access and engagement with outpatient providers.
The study aimed to evaluate effects of a transitional care practice (TC) that comprehensively addresses patients’ medical and psychosocial needs following hospital discharge. 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.Friday Letter Submission