September 16, 2011

Quality Partners of Rhode Island Publishes Study Demonstrating Reduced Hospital Readmissions among Coached Medicare Patients

First Study to Demonstrate the Real-World Impact of the Care Transitions Intervention

In the United States, 30-day hospital readmission rates for patients aged 65 years or older generally range from 20 to 25%, depending on clinical condition and geographic region. The Care Transitions Intervention (CTI, provides patient coaches to help patients navigate between their care providers during the days and weeks following hospital discharge, when they are at particularly high risk for hospital readmission. The goal is to help patients to understand their clinical conditions, track their medications, and recognize earlier when they need help so they can follow-up with their physician in a timely manner.

“In the CTI model, coaches empower patients to better self-manage their conditions,” says Rachel Voss, MPH, Program Coordinator at Quality Partners and lead author of a study in the July 25 issue of Archives of Internal Medicine. The study evaluates the real-world efficacy of the CTI and demonstrates a 39% reduction in the odds of hospital readmission among coached patients.

Quality Partners’ study is the first to demonstrate the efficacy of this intervention in the real-world conditions common among quality improvement projects. Previously, researchers linked the CTI to reduced hospital readmission using a randomized, controlled trial in a closed healthcare system in Colorado.

“Our work shows that, even outside of a controlled research environment, giving patients the tools to self-manage their own health conditions can improve outcomes and reduce health care utilization,” says Dr. Rebekah Gardner, Senior Medical Scientist at Quality Partners and a practicing internist at Rhode Island Hospital. “This type of intervention is particularly important at hospital discharge, when patients are the most vulnerable.”

As part of a Medicare pilot program to improve care transitions, Quality Partners offered coaching to Medicare patients hospitalized at five Rhode Island hospitals between January 2009 and June 2010. Coaching occurred for the first 30 days after hospital discharge, beginning in the hospital and then continuing at patients’ homes and over the phone after hospital discharge.

“Teaching the tenets of CTI’s ‘four pillars,’ the coaches taught patients to use a paper-based personal health record to track their medications and questions,” explains Ms. Voss. “Coaches encouraged them to make and keep follow-up appointments with their providers.”

“This intervention includes basic skills anchored in health literacy, common sense and our culture—and reinforcing these skills can help patients do better while simultaneously dramatically reducing healthcare utilization,” says Dr. Stefan Gravenstein, Clinical Director at Quality Partners and Professor of Medicine at the Alpert Medical School at Brown University.

The odds of hospital readmission within 30 days of discharge were significantly lower than among the 257 Medicare patients who received coaching, as compared to the patients not offered coaching.

"This model’s success demonstrates opportunities for providers to teach health behaviors as part of regular care,” says Dr. Gravenstein. “For example, providers can teach patients how to ask for help before health emergencies arise. If our healthcare community collaborates to systematically improve the way we help patients learn these skills, we have an opportunity to lead the country in efforts to improve health and lower costs."

Rhode Island is already a recognized leader in improving care transitions, with numerous Federal initiatives and a long history of standardized communication using the Continuity of Care Form. In March 2011, Quality Partners hosted a Transitions Summit featuring local and national panelists discussing strategies to further elevate care transitions locally. The Archives of Internal Medicine study provides an opportunity to translate results into sustainable systems change that elevates care for all patients, regardless of age or payor.

“Coaching addresses a known gap in healthcare delivery: after patients leave the hospital, but before they visit their doctor for follow-up care,” says Rosa Baier, MPH, Senior Scientist at Quality Partners and Teaching Associate at the Alpert Medical School at Brown University. “Our goal is to use the results from this study to help close that gap, by changing how and when healthcare providers and patients communicate with one another. We’re collaborating with our community partners to implement a series of evidence-based practices designed to further improve patient safety during care transitions. We published these best practices in the Rhode Island Medical Society’s journal in June.”

Quality Partners is also working to spread coaching through partnerships with other Rhode Island projects, including the Aging and Disability Resource Center and the Beacon Communities Program. To learn more about these efforts or the care transitions best practices, visit

About Quality Partners of Rhode Island:
Quality Partners of Rhode Island is a non-profit healthcare quality improvement organization based in Providence, Rhode Island that provides consulting, research and education services. We collaborate with national and local government agencies, healthcare providers, stakeholders, insurers, educational institutions and foundations on many healthcare quality improvement initiatives. With a staff of over 40 physicians, nurses, educators, analysts and other healthcare professionals, this agency is viewed within the healthcare industry as a local and national leader in quality improvement. Quality Partners is a vendor in the Regional Extension Center (REC) Marketplace, as well as the Quality Improvement Organization for the state of Rhode Island.