Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions
Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions
The objective of this study is to design and implement a set of procedures (the intervention)
 to improve patients' experiences when they are discharged home from the hospital. Second,
 this study aims to look at how the intervention affects problems that are known to occur
 after discharge, including medication issues, worsening medical problems, or readmission to
 the hospital. The investigators will study how well patients recover the ability to do the
 things they could before they were admitted to the hospital and their opinions of the
 discharge process. Lastly, this study will look to understand the best way to implement the
 intervention into different hospitals and practices, and which types of patients benefit from
 it most.
The specific aims of this study are:

 1. To develop, implement, and refine a multi-faceted, multi-disciplinary transitions
 intervention with contributions from hospital and Patient-Centered Medical Home (PCMH)
 personnel.

 Hypothesis: a collaborative transitions intervention can be designed and implemented
 within an ACO that reliably provides the components of an ideal transition in care.

 2. To evaluate the effects of this intervention on post-discharge adverse events,
 functional status, patient engagement, and emergency department and hospital utilization
 within 30 days of discharge.

 Hypothesis: compared with usual care, a collaborative transitions intervention will
 decrease post discharge adverse events, improve post-discharge functional status,
 increase patient engagement, and reduce emergency department and hospital utilization in
 the post-discharge period.

 3. To understand barriers to and facilitators of successful implementation of this
 intervention across practices.

 Hypothesis: several barriers to and facilitators of implementation can be identified and used
 to create lessons learned for other health systems to successfully implement this type of
 intervention.
Inclusion Criteria:

 Potential subjects will be adult patients admitted to medical and surgical services at BWH
 and MGH, likely to be discharged back to the community, and whose PCP belongs to one of the
 Partners Community Healthcare, Inc. (PCHI) primary care practices that has met "Primed"
 criteria for being a PCMH, admits at least 2 patients to BWH or MGH, and has agreed to
 participate. Primed criteria are a standard set of requirements that cover 6 essential
 building blocks of PCMH practices: electronic health record, patient portal, team-based
 care, practice redesign, care management, and identification of high-risk patients. We
 estimate that of the approximately 300 PCHI adult primary care practices, 150 of them will
 meet PCMH criteria during the study and that 20 of them will qualify and be willing to
 participate in the study. We estimate that 12,000 such patients will be admitted to BWH and
 MGH over the 18-month study period, of which we will enroll 1700 patients. These patients
 are broadly representative of hospitalized patients and include several vulnerable
 populations, including the elderly (33% 65 or older), patients with multiple chronic
 conditions (47% with Elixhauser comorbidity score 5 or more), and racial and ethnic
 minorities (14% African American, 13% Latino).

 Exclusion Criteria:

 1. Likely discharge to a location other than home (or to a caregiver's home)

 2. Police custody

 3. No telephone or homeless

 4. Previous enrolment in the study

 5. Patient unable to communicate in either English or Spanish