Archives of internal medicine
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Multicenter Study Comparative Study
The care transitions intervention: translating from efficacy to effectiveness.
Well-executed communication among hospital providers, patients, and receiving providers at the time of hospital discharge contributes to better health outcomes and lower overall health care costs. The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system but requires real-world testing to establish effectiveness in other settings. We hypothesized that coaching would reduce 30-day readmission rates for fee-for-service Medicare beneficiaries, even in open, urban health care delivery systems. ⋯ The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.