Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients

Honora Englander, Devan Kansagara

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

Background: Uninsured and Medicaid patients are particularly vulnerable as they transition from hospital to home. Transitional care improvement programs require time and capital, incentives for which may be unclear for those lacking a third-party payor. This article describes our experience developing a hospital-funded transitional care program for uninsured and Medicaid patients. Methods: We performed an inpatient needs assessment, convened multi-stakeholder work groups, and engaged institutional change-agents to inform program development and a business case. Results: We mapped needs to specific program elements, including a transitional care nurse, pharmacy consult and provision of medications for uninsured patients, medical home linkages including community payment for medical homes, and monthly quality improvement meetings. A business case was informed by local needs and utilization data, and compelled the hospital to invest in up-front resources for this population. DISCUSSION: We are studying our program's impact on 30-day readmission and emergency department rates through a clustered, randomized controlled trial. Lessons from our experience may be useful to others aiming to improve care for socioeconomically disadvantaged patients.

Original languageEnglish (US)
Pages (from-to)524-529
Number of pages6
JournalJournal of Hospital Medicine
Volume7
Issue number7
DOIs
StatePublished - Sep 2012

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Patient Transfer
Medicaid
Patient-Centered Care
Health Insurance Reimbursement
Program Development
Needs Assessment
Vulnerable Populations
Quality Improvement
Hospital Emergency Service
Motivation
Inpatients
Randomized Controlled Trials
Nurses
Economics
Population
Transitional Care

ASJC Scopus subject areas

  • Health Policy
  • Assessment and Diagnosis
  • Care Planning
  • Fundamentals and skills
  • Leadership and Management

Cite this

Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients. / Englander, Honora; Kansagara, Devan.

In: Journal of Hospital Medicine, Vol. 7, No. 7, 09.2012, p. 524-529.

Research output: Contribution to journalArticle

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