Mathematica Study—Effective Transitional Care Intervention: Coleman et al. (2006)
- Used advanced practice nurses (APNs) as transition coaches.
- Targeted patients hospitalized for various conditions.
- Patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care, (3) continuity/ guidance from transition coach.
- Randomized controlled trial (RCT) (379 treatment, 371 control).
- Lowered rehospitalization rates at 90 days: For any reason (17% vs. 23%); For initial condition (5% vs. 10%).
- Lowered hospital costs 19% over 180 days ($2,058 vs. $2,546).
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