Implementation of a care transitions model for low-income older adults: a high-risk, vulnerable population

Low-income older adults are particularly vulnerable during care transitions. The present study evaluated the effectiveness of a transitional care model in this population. A quasi-experimental design was used to compare outcomes in the intervention group with historical controls at 30, 90, 180, and 365 days after discharge, along with a pre-postintervention evaluation of the intervention group. Eligible individuals were age 60 and older hospitalized between June 2008 and January 2009. Main outcome measures were readmissions, emergency department (ED) visits, and primary care services use. Of 121 participants, 55% were female and 90% African American, with a mean age of 69. Readmission rates were generally but not significantly lower in the intervention group than in controls (Day 30, 9.6% vs 17.3%; Day 90, 28.9% vs 25.0%; Day 180, 32.7% vs 36.5%; Day 365, 44.2% vs 53.9%; P > .05), as were ED visit rates (Day 30, 17.3% vs 15.4%; Day 90, 32.7% vs 34.6%; Day 180, 38.5% vs 40.4%; Day 365, 50.0% vs 55.8%; P > .05). Primary care service utilization rates were significantly higher in the intervention group than in controls at Day 30 (40.4% vs 19.2%, P < .001), 90 (74.9% vs 32.7%, P < .001), and 180 (65.4% vs 32.7%, P < .001). The lack of statistically significant reduction in readmissions and ED visits with the intervention, may suggest the need for additional assistance during care transitions for this vulnerable population.