Effectiveness of a national transitional care program in reducing acute care use

Journal of the American Geriatrics Society

Volumn 62, Issue 4, 2014, Pages 747-753

  Wee, Shiou Liang ^a,b   Loke, Chok Kang ^c   Liang, Chun ^c   Ganesan, Ganga ^c   Wong, Loong Mun ^a   Cheah, Jason ^a  

^a Agency for Integrated Care   (Singapore)

^b DUKE NUS MEDICAL SCHOOL   (Singapore)

^c MINISTRY OF HEALTH   (Singapore)

Author keywords

care coordination; rehospitalizations; Singapore

Indexed keywords

AGED; AGED CARE TRANSITION PROGRAM; ARTICLE; CAREGIVER; CONTROLLED STUDY; EMERGENCY CARE; EMERGENCY WARD; FEMALE; FOLLOW UP; GENERAL HOSPITAL; HEALTH PROGRAM; HOSPITAL DISCHARGE; HOSPITAL READMISSION; HOSPITALIZATION; HUMAN; MAJOR CLINICAL STUDY; MALE; PATIENT CARE; PROFESSIONAL PRACTICE; PROGRAM EFFECTIVENESS; PROPENSITY SCORE; QUALITY OF LIFE; SELF CARE; SINGAPORE; SOCIAL SUPPORT; SOCIAL WELFARE;

CARE COORDINATION; REHOSPITALIZATIONS; SINGAPORE;

ACTIVITIES OF DAILY LIVING; ACUTE DISEASE; AGED; DISEASE MANAGEMENT; EMERGENCY SERVICE, HOSPITAL; FEMALE; GERIATRIC ASSESSMENT; HUMANS; MALE; NATIONAL HEALTH PROGRAMS; PATIENT READMISSION; PREVALENCE; PROGRAM EVALUATION; RETROSPECTIVE STUDIES; SINGAPORE;

EID: 84898783650     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/jgs.12750     Document Type: Article

References (32)

1. Jencks SF, Williams MV, Coleman EA,. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: 1418-1428.
2. Ashton CM, Kuykendall DH, Johnson ML, et al. The association between the quality of inpatient care and early readmission. Ann Intern Med 1995; 122: 415-421.
3. Kangovi S, Grande D,. Hospital readmissions-not just a measure of quality. JAMA 2011; 306: 1796-1797.
4. van Walranven C, Bennet C, Jennings A, et al. How important is it to identify avoidable hospital readmissions with certainty? Can Med Assoc J 2011; 183: E368-E369.
5. Coleman EA, Boult C,. Position Statement of the American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003; 51: 556-557.
6. Coleman EA,. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003; 51: 549-555.
7. Weinberger M, Oddone EZ, Henderson WG,; for the Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Does increased access to primary care reduce hospital readmissions? New Engl J Med 1996; 334: 1441-1447.
8. Peikes D, Chen A, Schore J, et al. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009; 301: 603-618.
9. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004; 52: 675-684.
10. Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. J Am Geriatr Soc 2004; 52: 1817-1825.
11. Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention. Results of a randomized controlled trial. Arch Intern Med 2006; 166: 1822-1828.
12. Lim E, Matthew N, Mok W, et al. Using hospital readmission rates to track the quality of care in public hospitals in Singapore. BMC Health Serv Res 2011; 11 (Suppl 1): A16.
13. Khalid S,. Hospital bed crunch looms in the next few years. December 8, 2011. Available at http://www.healthxchange.com.sg/News/Pages/hospital-bed- crunch-looms-years.aspx Accessed January 26, 2014.
14. Khaw BW,. Healthcare 2011. From Institution to Home-Health Budget Discussion, 27 Jan 2011 [on-line]. Available at http://mohsingapore.sg/2011/01/ healthcare-2011-from-institution-to-home/ Accessed February 29, 2012.
15. The care transitions program [on-line]. Available at http://www. caretransitions.org/structure.asp Accessed February 29, 2012.
16. Luo N, Chew LH, Fong KY, et al. Validity and reliability of the EQ-5D self-report questionnaire in Chinese-speaking patients with rheumatic diseases in Singapore. Ann Acad Med Singapore 2003; 32: 685-690.
17. Bakshi BA, Wee SL, Tay C, et al. Validation of the care transition measure in multi-ethnic Southeast Asia in Singapore. BMC Health Serv Res 2012; 12: 256.
18. Coleman EA, Mahoney E, Parry C,. Assessing the quality of preparation for posthospital care from the patient's perspective-the care transitions measure. Med Care 2005; 43: 13-17.
19. The care transition measure [on-line]. Available at http://www. caretransitions.org/ctm-main.asp Accessed March 22, 2012.
20. Rosenbaum PR, Rubin DB,. The central role of the propensity score in observational studies for causal effects. Biometrika 1983; 70: 41-55.
21. van Walraven C, Dhalla IA, Bell C, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Can Med Assoc J 2010; 182: 551-557.
22. Kagen D, Theobald C, Freeman M,. Risk prediction models for hospital readmission. A systematic review. JAMA 2013; 306: 1688-1698.
23. Lunceford JK, Davidian M,. Stratification and weighting via the propensity score in estimation of causal treatment effects: A comparative study. Stat Med 2004; 23: 2937-2960.
24. Freedman DA, Berk RA,. Weighting regressions by propensity scores. Eval Rev 2008; 32: 392-409.
25. Leslie S, Thiebaud P, et al. SAS Global Forum 2007 statistics and data analysis using propensity scores to adjust for treatment selection bias SAS Global Forum 2007 statistics and data analysis. SAS Global Forum 2007-Statistics and Data Analysis, Paper 184-2007: 1-4.
26. Boutwell A, Griffin F, Hwu S, et al. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement, 2009.
27. Ornstein K, Smith KL, Foer DH, et al. To the hospital and back home again: A nurse practitioner-based transitional care program for hospitalized homebound people. J Am Geriatr Soc 2011; 59: 544-551.
28. Ohuabunwa U, Jordan Q, Shah S, et al. Implementation of a care transitions model for low-income older adults: A high-risk, vulnerable population. J Am Geriatr Soc 2013; 61: 987-992.
29. Gray LC, Travers CM, Bartlett HP, et al. Transition care: Will it deliver? Med J Aust 2008; 188: 251-253.
30. Brown RS, Peikes D, Peterson G, et al. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff (Millwood) 2012; 31: 1156-1166.
31. Pappas G, Hadden WC, Kozak LJ,. Potentially avoidable hospitalizations: Inequalities in rates between US socioeconomic groups. Am J Public Health 1997; 87: 811-816.
32. Hospital services [on-line]. Available at http://www.moh.gov.sg/content/ moh-web/home/our-healthcare-system/Healthcare-Services/Hospitals.html Accessed October 20, 2013.