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

Honora Englander, Devan Kansagara

Research output: Contribution to journalArticlepeer-review

18 Scopus citations


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
Issue number7
StatePublished - Sep 2012

ASJC Scopus subject areas

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


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