Effects of a Transitional Care Practice for a Vulnerable Population: A Pragmatic, Randomized Comparative Effectiveness Trial

Key Questions Answered
  • Does a tailored transitional care intervention reduce inpatient admissions and acute care utilization among high-risk adults following a hospital discharge?
  • What are the elements of an effective transitional care model, including: (1) patient identification for the intervention; (2) intervention elements; and (3) staff team members?
Key Themes and Takeaways

At Northwestern Medical Group in Chicago, a patient-centered transitional care intervention serving patients with complex health needs that lack a usual source of care was found to reduce the likelihood of inpatient admissions within 90 and 180 days post-discharge by at least 35 percent in a randomized comparative effectiveness trial. There was no significant reduction in hospital encounters within 90 days.

The study results, published in the May 2019 Journal of General Internal Medicine, suggest that individually tailored transitional care interventions, when targeted to patients with complex health needs who predominantly are uninsured or Medicaid enrollees, may lead to improved patient self-management and reduced utilization of some types of acute care over a longer time horizon than the traditionally-evaluated measure of 30-day readmission rates.

Components of the transitional care intervention included:

  • A scheduled transitional care practice appointment within 10 days post-discharge, to include multidisciplinary team-based services that address medical and psychosocial needs.
  • The development of a patient-centered, individually tailored care plan inclusive of interventions such as connections to federal and state entitlements, simplification of medication regimens, and behavioral health treatment.
  • Follow-up appointments at the transitional care practice scheduled as needed, with most patients seen weekly.
  • Connections to community-based primary care providers after the patient and care team identified a readiness to leave the transitional care practice and engage in self-management.

related blog post provides additional detail on how transitional care has been implemented at Northwestern Medical Group in Chicago, as well as important considerations for health plan leaders who are interested in implementing a transitional care program. See also a related Better Care Play that outlines how health care organizations can develop an integrated, person-first approach to transitional care post-discharge.

David T. Liss
Ronald T. Ackermann
Andrew Cooper
Emily A. Finch
Courtney Hurt
Nicola Lancki
Angela Rogers
Avani Sheth
Caroline Teter
Christine Schaeffer
Population Addressed
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Uploaded to The Playbook