• David T Liss, Ronald T Ackermann, Andrew Cooper, Emily A Finch, Courtney Hurt, Nicola Lancki, Angela Rogers, Avani Sheth, Caroline Teter, and Christine Schaeffer.
• Center for Community Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. david.liss@northwestern.edu.
• J Gen Intern Med. 2019 Sep 1; 34 (9): 1758-1765.

BackgroundThere is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.ObjectiveEvaluate effects of a transitional care practice (TC) that comprehensively addresses patients' medical and psychosocial needs following hospital discharge.DesignPragmatic, randomized comparative effectiveness trial.PatientsAdults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care.InterventionsTC 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 MeasuresThe 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 ResultsFour 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).ConclusionsAmong 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.Trial Registrationclinicaltrials.gov identifier NCT03066492.

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