期刊
HEALTH AFFAIRS
卷 31, 期 12, 页码 2659-2668出版社
PROJECT HOPE
DOI: 10.1377/hlthaff.2012.0366
关键词
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资金
- VA Transformation-21 Grant, Patient-Centric Alternatives to Institutional Extended Care
- Madison VA Geriatrics Research, Education, and Clinical Center (GRECC) [2012-08]
- National Institute on Aging [K23AG034551]
- National Institute on Aging, in partnership with the American Federation for Aging Research
- John A. Hartford Foundation
- Atlantic Philanthropies
- Starr Foundation
- University of Wisconsin School of Medicine and Public Health's Health Innovation Program
- Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research
- Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health [1UL1RR025011]
- VA Office of Geriatrics and Extended Care in the VA Central Office
- Veterans Integrated Service Network 12
- William S. Middleton Memorial Veterans Hospital
The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.
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