Older adults use the emergency department (ED) as an important source of acute care, making 20 million ED visits annually. Older adults who visit the ED do not have conditions of sufficient severity to warrant hospital admission; thus, they are treated and discharged home. Unfortunately, older adults do poorly after being discharged home from the ED, with 20% having repeat ED visits within 30 days. The ED-to-home transition has been identified as a cause for these avoidable poor outcomes, but ED-focused interventions to improve this transition have had inconclusive outcomes and have suffered from feasibility, sustainability and scalability problems. Coleman's Care Transition Intervention (CTI) has been validated to improve the hospital-to-home transition, decreasing both hospital readmissions and costs. The CTI uses coaches, usually nurses or social workers, to support patients being discharged home by transferring skills to activate patients. Applying the CTI to the ED- to-home transition is a natural extension, but it has not been evaluated in this unique and demanding setting. In this study, we will test our overall hypothesis that the community-based, paramedic-coordinated ED- to-home CTI will improve community-dwelling older adults' post-ED health outcomes and reduce costs. We will evaluate CTI process outcomes by testing if participants randomized to the CTI demonstrate better understanding of red flags that indicate a worsening of their condition, implement medication changes more frequently, and follow up with their primary care physicians more rapidly after ED discharge, as compared to the control group. We will also evaluate the effectiveness and cost-effectiveness of the CTI by testing if participants randomized to the CTI have improved Patient Activation Measure scores 30 days after discharge, have decreased frequency of ED use, and decreased health care costs within 30 days of ED discharge. Additionally, we recognize that the CTI will not eliminate all repeat ED visits. Thus, we will identify factors independently associated with repeat ED visits among CTI recipients such that future programs can ensure their needs are adequately addressed. This research will provide critical empiric evidence regarding the significant problem of poor ED-to-home transitions. By leveraging the CTI, a widely available and efficient intervention and paramedics, a highly-skilled and respected health care provider present in all communities, we will apply an innovative approach to improve older adults' health following an ED visit. Through rigorous research, we will test the effectiveness and cost- effectiveness of this approach, with a specific focus on ultimate sustainability and dissemination.

Public Health Relevance

The emergency department (ED) is a common source of acute illness care for older adults. Many older adults who are discharged home from the ED return within 30 days due to numerous challenges faced during the ED- to-home transition. Unless programs to improve the ED-to-home transition are identified, the health and financial costs will only increase as the older adult population doubles by 2040. This study will apply Coleman's Care Transitions Intervention to the ED-to-home transition by adapting the program to account for the unique aspects of the ED setting. The research will evaluate the process, ED use, and cost outcomes of a community- based, paramedic-coordinated Care Transitions Intervention. Upon completion, this study will provide empiric evidence regarding this innovative approach to help the rapidly growing older adult population remain healthy and independent after an ED visit.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Project (R01)
Project #
5R01AG050504-05
Application #
9690517
Study Section
Community-Level Health Promotion Study Section (CLHP)
Program Officer
Radziszewska, Barbara
Project Start
2015-08-15
Project End
2021-04-30
Budget Start
2019-05-01
Budget End
2021-04-30
Support Year
5
Fiscal Year
2019
Total Cost
Indirect Cost
Name
University of Wisconsin Madison
Department
Emergency Medicine
Type
Schools of Medicine
DUNS #
161202122
City
Madison
State
WI
Country
United States
Zip Code
53715
DuGoff, Eva H; Fernandes-Taylor, Sara; Weissman, Gary E et al. (2018) A scoping review of patient-sharing network studies using administrative data. Transl Behav Med 8:598-625
Shah, Manish N; Hollander, Matthew M; Jones, Courtney Mc et al. (2018) Improving the ED-to-Home Transition: The Community Paramedic-Delivered Care Transitions Intervention-Preliminary Findings. J Am Geriatr Soc 66:2213-2220
Mi, Ranran; Hollander, Matthew M; Jones, Courtney M C et al. (2018) A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits. BMC Geriatr 18:104
Lau, Hunter Singh; Hollander, Matthew M; Cushman, Jeremy T et al. (2018) Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention. Prehosp Emerg Care 22:527-534
Dattalo, Melissa; DuGoff, Eva; Ronk, Katie et al. (2017) Apples and Oranges: Four Definitions of Multiple Chronic Conditions and their Relationship to 30-Day Hospital Readmission. J Am Geriatr Soc 65:712-720