The Care Transitions Intervention helps patients receive better care by encouraging them to assert a more active role in their health care. Patients receive specific tools and skills that are reinforced by a ‘transition coach’ who follows patients across settings for the first 30 days after leaving the hospital. Eric Coleman, MD, an associate professor at the University of Colorado at Denver and Health Sciences Center’s School of Medicine and his colleagues found that patients who participated in the intervention were less likely to require re-hospitalisation, significantly cutting their health care costs. These findings are particularly pertinent to older individuals with complex care needs.

While the intervention yielded immediate results, the skills acquired by the patient also had long-term positive effects. “We were excited to see the significant reduction in hospital readmissions during the first 30 days while the coach was involved. What was even more exciting, however, was the finding that these patients were significantly more likely to stay out of the hospital up to six months later,” Coleman said.

The transition coach works with patients and their families to improve care in four areas, referred to as “pillars”: medication self-management, the creation of a personal health record maintained by the patient, obtaining timely follow up care and developing a plan to best seek care if particular target symptoms arise.

Beyond the benefits to the patient, the intervention lowers costs for Medicare providers who would otherwise finance the re-admissions to hospital. Because the intervention opens beds for other patients, hospitals may benefit financially. Researchers estimate that for every 350 patients who receive the intervention, hospital costs will be reduced by approximately $300,000.

MEDICA.de; Source: University of Colorado at Denver