Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

Area of Science:

• Gerontology
• Palliative Care
• Health Services Research

Background:

• The Coordinated Transitional Care (CTraC) program, a telephone-based, nurse-driven intervention, has demonstrated success in reducing hospital readmissions.
• Serious illness in veterans necessitates high-quality transitional and end-of-life care, an area where existing programs may be suboptimal.

Purpose of the Study:

• To implement and evaluate an adapted CTraC program, named Supportive CTraC, aimed at enhancing transitional and end-of-life care for veterans with serious illnesses.
• To assess the feasibility and effectiveness of a nurse case manager-led intervention in aligning care with veteran values and optimizing care delivery.

Main Methods:

• The Replicating Effective Programs (REP) framework guided the adaptation and implementation of the Supportive CTraC program.
• A registered nurse case manager provided protocolized, intensive phone-based case management to veterans with life-limiting diagnoses not enrolled in hospice.
• Outcomes were evaluated using 1:1 matching with a comparison group, Kaplan-Meier plots, and Cox-Proportional Hazards models to assess palliative care use, acute care utilization, and survival.

Main Results:

• The Supportive CTraC program enrolled 104 veterans with high fidelity over 1.5 years.
• Enrollees showed a 61% increased likelihood of hospice enrollment compared to the control group.
• Supportive CTraC patients had significantly fewer ICU admissions and were more likely to die at home with hospice services.

Conclusions:

• A nurse-driven transitional care program, Supportive CTraC, is feasible for implementation in veteran healthcare systems.
• The program effectively improved key end-of-life care outcomes, including hospice utilization and place of death.
• Supportive CTraC demonstrates potential for enhancing the quality of care for veterans facing serious illness.