Effects of a transitional care practice for a vulnerable population: A pragmatic, randomized comparative effectiveness trial

Background: There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.

Objective: Evaluate effects of a transitional care practice (TC) that comprehensively addresses patients’ medical and psychosocial needs following hospital discharge.

Design: Pragmatic, randomized comparative effectiveness trial.

Patients: Adults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care.

Interventions: TC intervention included a scheduled post-discharge appointment at the TC practice, where a multidisciplinary team comprehensively assessed patients’ medical and psychosocial needs, addressed modifiable barriers, and subsequent linkage to a new primary care source. Routine Care involved assistance scheduling a post-discharge appointment with a primary care provider that often partnered with the hospital where the initial encounter occurred.

Main Measures: The primary outcome was a binary indicator of death or additional hospital encounters within 90 days of initial discharge. Secondary outcomes included any additional hospital encounters, and counts of hospital encounters, over 180 days.

Key Results: Four hundred ninety patients were randomized to TC intervention and 164 to Routine Care; 34.6% were uninsured, 49.7% had Medicaid, and 57.4% were homeless or lived in a high-poverty area. There was no significant difference between arms in the 90-day probability of death or additional hospital encounters (relative risk [RR] 0.89; 0.91; 95% confidence interval [CI] 0.74–1.13). However, TC patients had 37% and 35% lower probability of any inpatient admission over 90 days (RR 0.63; 95% CI 0.43–0.91) and 180 days (RR 0.65; 95% CI 0.47–0.89), respectively. Over 180 days, TC patients had 42% fewer inpatient admissions (incidence rate ratio 0.58; 95% CI 0.37–0.90).

Conclusions: 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.

This article is included in the PCORI Social Needs Interventions to Improve Health Outcomes Evidence Map. Click here to access evidence map.