The care transitions intervention: translating from efficacy to effectiveness.
The Partnership for Patients has set a goal of reducing preventable hospital readmissions 20% by the year 2013. This goal was achieved by the landmark care transitions study. However, since that study was conducted in an integrated health care system, concerns linger about the generalizability of the intervention to other settings. This study, funded by the Centers for Medicare and Medicaid Services, sought to evaluate the real world effectiveness of the care transitions intervention at six hospitals in a non-integrated health care system. Despite logistical challenges, the intervention successfully reduced readmissions by 36% in patients who received it compared with patients who did not receive any component of the intervention. As hospitals continue to investigate ways of preventing readmissions and reducing adverse events after discharge, this study provides reinforcement for comprehensive interventions that attempt to bridge the gap between inpatient and outpatient care.