Transitional Care Model Evaluation 2020
Transitional Care Model Evaluation 2020
The study is a randomized controlled trial to estimate the effects of the transitional care
 model (TCM) on hospital admissions and patients' experience during the year following the
 patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will
 be the coordinating center for the implementation. The study will be conducted in four large
 health systems spread throughout the U.S., drawing patients from 9 hospitals in those
 systems. Eligible patients are older adults (age 65 and older) admitted to a participating
 hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD),
 or pneumonia (PNA). The evaluation will be conducted by Mathematica.
The Transitional Care Model (TCM) is an advanced practice registered nurse (APRN) led,
 team-based, care management strategy designed to improve the care and outcomes of high-risk
 older adults transitioning from hospital to home. Eligible patients who agree to participate
 in the study will be randomly assigned to either the intervention group, which receives the
 TCM intervention, or the control group, which receives usual care (standard hospital
 discharge planning and post-hospital follow up services). The target sample size for the
 study is 1600, evenly divided into intervention and control groups, with 400 patients
 recruited from each of the 4 partnering health systems (Swedish, Trinity Health, University
 of California, San Francisco, and Veterans Health Administration (VHA) - St Louis and
 Cleveland). Data will be collected at intake, prior to randomization, by enrollment
 coordinators at each of the participating hospitals. Followup data will be collected in a
 survey of patients conducted 90 days after discharge, and from claims data obtained from
 Medicare, Medicare Advantage plans, and the VHA.
Inclusion Criteria:

 -  Age 65 years and older

 -  Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF
 or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis

 -  English and non-English speaking, able to respond to questions

 -  Reachable by telephone after discharge

 -  Resides within the geographic service area

 -  Consent to participation

 Exclusion Criteria:

 -  Enrolled in Medicare's Hospice or End-Stage Renal Disease programs

 -  Presence of active and untreated psychiatric conditions (ICD10: F10-F29)

 -  Long-term care resident

 -  Undergoing active cancer treatment

 -  Currently enrolled in another RCT