jueves, 13 de mayo de 2010

AHRQ Innovations Exchange | Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs


Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs

Snapshot
Summary

Under a program known as the Care Transitions Intervention, a transition coach encourages Medicare patients who have been hospitalized for any of 11 common complex conditions to assert a more active role in their own care following hospital discharge. The program reduced hospital readmissions and costs, even in a heavily penetrated Medicare Advantage market in which the reduction of hospital use has been an explicit focus for many years.

See the Description of the Innovative Activity section for changes to the Transition Coach role and the Getting Started with This Innovation section for more items to consider when implementing the Innovation (updated May 2010).

Evidence Rating
Strong: The evidence consists of a 750-subject randomized controlled trial (RCT) that evaluated the program's impact on hospital readmissions, along with estimates of cost savings based on the results of this RCT.

Developing Organizations
Care Transitions Program, University of Colorado at Denver

Date First Implemented
2002

Patient Population
Geographic Location > Nation; State; Vulnerable Populations > Medically or socially complex


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AHRQ Innovations Exchange | Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs

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