Healthcare Headlines Blog

Transitional Care Interventions Help Heart Patients Do Better, Right? With February being Heart Month, and knowing that heart disease is one of the readmission penalty diagnoses, I paid attention when I recently read a study in Annals of Internal Medicine from investigator Janet Prvu Bettger and collaborators from Duke and Wake Forest.[i] This study looked at the role of transitional care interventions in patients who had recently suffered a heart attack or stroke. The question was legitimate:  what interventions around transitions work to improve outcomes? What they found was sobering.


The investigators looked at 12 years of literature aimed at four types of interventions – patient education, community-based support, hospital-initiated support and chronic disease management. The evidence, though only of “moderate” strength, showed that hospital-initiated interventions “reduced the number of total hospitalized days without adversely affecting long-term functional recovery or death after stroke and reduced death after MI [or myocardial infarction – heart attack].”

For MI, the investigators, who found and reviewed (only!) 17 studies that compared interventions to the usual standard of care, were looking at the following components of transitional care: self-management, discharge planning, case management across care settings and access to information. Only four studies were “good” quality and most were not even from the United States, so the actual interventions and applicability might be questionable.

Even so, what works? Patient education? Community-based support?  Chronic disease management?  Adverse event monitoring?  All had “insufficient” evidence to support their use.  Only hospital-initiated interventions had any support, albeit “low” evidence from six studies, and only three of the six showed reduced mortality and one showed reduced illness perception and symptoms.

Although we may be tempted to wait until we know better what to do, we can’t wait. Why not? The now famous Jencks et al  2009 New England Journal of Medicine study found that one in five Medicare patients were rehospitalized within 30 days, half never saw outpatient physician after discharge, 70 percent of surgical readmissions were for chronic medical conditions, and the rehospitalizations cost Medicare as much as $17.4 billion.[ii] This is simply no longer acceptable from either a patient care, a care provider (us) or a financial standpoint.

Even with imperfect science, Kindred is applying the lessons reported in the literature, although we tend to be less disease-specific and look more at a general population of patients with multiple conditions, reflecting our patients and residents. Our Skilled Nursing Facilities (SNFs) began adopting the INTERACT transfer process in 2012, and our hospitals are working on an implementation plan for tools largely adapted from BOOST and INTERACT.

In Massachusetts, a pilot Care Management Program is following an intervention group that will receive additional structured patient encounter follow-ups and transition coaching throughout the entire episode of care, in addition to current discharge planning processes. Newly hired and trained Transitional Care Nurses will manage the care transitions for a group of consented patients who start their episode of care at one of our Transitional Care Hospitals. They will help reconcile medications, ensure proper follow-up appointments are made with primary care and specialty physicians, educate patients and family members about the signs and symptoms of new problems, and coordinate care with Kindred team members on each end of the care transition. So we can judge its service effectiveness, they will also be responsible for overseeing the completion of a patient satisfaction survey following each transition of care as well as upon transition from the lowest Kindred level of care. We are doing the same in our Indianapolis market.

Are we right to dive in, or should we wait until evidence-based medicine makes us more certain it will pay off, and until unintended consequences are better known?  I’d love to hear your thoughts and feedback.

 [i] Prvu Bettger J, Alexander KP, Dolor RJ, Olson DM, Kendrick AS, Wing L, Coeytaux RR, Graffagnino C, Duncan PW. Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review. Ann Intern Med. 2012 Sep 18;157(6):407-16. doi: 10.7326/0003-4819-157-6-201209180-00004.

[ii] Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563.

By Sean Muldoon, MD