Development and Implementation of the Coordinated-Transitional Care (C-TraC) Program.

Abstract

The transition from hospital to home is increasingly recognized as a time of heightened risk for vulnerable patients, particularly older adults. Poor-quality transitions have been associated with preventable negative outcomes, including postdischarge medication errors, interruptions in care plans, and avoidable 30-day rehospitalizations.1-8 Nearly 1 in 5 older adults is rehospitalized within 30 days of discharge at a total combined cost of more than $25 billion per year.4,9,10 Patient factors likely to contribute to negative postdischarge outcomes include complex comorbid conditions, cognitive and functional impairments, and limited emotional support.10,11 System-related factors also likely to contribute to poor postdischarge outcomes include poor communication between providers across settings, limited access to services, and inadequate patient and family caregiver education.8 As a result, patients and caregivers are often unprepared for the realities of taking care of patient needs and recovery at home, which leads to high levels of dissatisfaction, disruptions in care continuity, and an increased risk for adverse outcomes, such as medication discrepancies and rehospitalization.1,8 Transitional care programs directly address these issues.3,12-14 Transitional care programs typically employ nurses or other health care professionals to support and empower patients during the predischarge period, effectively bridging the hospital and home.3,12-14 Most of these programs incorporate in-home visits soon after the hospital discharge to educate a patient about his or her medication management, to plan for medical follow-up, to look for signs of worsening medical conditions and how to respond to them, and to develop a personal health record.3,12-14 Research suggests that such transitional care programs can improve patient satisfaction and safety and can decrease rehospitalizations by about one-third.3,12-14 Despite these advances, currently available transitional care programs are not appropriate for all hospitals or patients. None of the proven transitional care programs target patients who might have difficulty participating in predischarge education, such as older adults with dementia, and none have been designed for use within a VA system. Also, because it is difficult to send staff great distances to perform in-home visits, transitional care programs with in-home components are not a good fit for hospitals with patients who come from many miles away, such as those in rural areas. VA hospital settings in particular often serve patient populations with a wide geographic dispersion, limiting the use of existing transition care interventions. The William S. Middleton Memorial Veterans Hospital (MVAH) in Madison, Wisconsin, is an 87-bed general VA hospital with 4,400 admissions annually, serving veterans throughout a 3-state area. About 75% of this patient population lives too far from the hospital to receive home visit services. Because no existing evidence-based transitional care programs addressed the transitional care challenges faced by the MVAH, the researchers developed the VA Coordinated-Transitional Care (C-TraC) Program as a Geriatric Research Education and Clinical Center (GRECC) clinical demonstration project. Based at the MVAH, the GRECC opened in 1991 and has established numerous clinical, education, and research initiatives that focus on Alzheimer disease and other dementias. C-TraC combines VA telemedicine principles with standard protocols adapted from Coleman’s Four Pillars of transitional care.3 The program launched in 2010 with the overarching goal of improving care coordination and outcomes among high-risk hospitalized veterans discharged to community settings. Through its first 18 months of operation, C-TraC proved to be a low-cost program that harnessed existing VA resources to improve key postdischarge outcomes, such as 30-day rehospitalizations, leading to significant cost avoidances.15 This article discusses the development and implementation of the C-TraC program.