Evaluation of a Community-based Care Transitions Program to Reduce 30-day Readmissions Using the RE-AIM Framework

Reducing hospital readmissions has become a national priority to improve the quality of care and lower health care spending. Section 3026 of the Affordable Care Act of 2010 created the Community-based Care Transition Program (CCTP) to reduce 30-day all-cause readmissions in the Medicare FFS population. A CCTP program called the Community Passport 2 Care (ComPass2c) was implemented in nine hospitals in New England. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) was used to evaluate the ComPass2c program in reducing 30-day readmissions in Medicare FFS beneficiaries discharged from one academic hospital in New England. A retrospective analysis of the ComPass2c program was performed. Eight hundred thirty-two subjects enrolled in the ComPass2c program; 61% were female with a mean age of 79 years (SD = 13). Using linear regression, the unadjusted 30-day all-cause readmission rate decreased by 0.5% each quarter (p = .03) for the first eight quarters of the ComPass2c program with a relative risk reduction of 23%. The ComPass2c program reached 32% of eligible Medicare FFS beneficiaries at Hospital X. Implementation for post-discharge phone calls was 89% and 34% for post-discharge home visits. The mean change in patient activation scores was 0.15 (SD = 4.79) without a significant change in activation level (χ2 (6) = 3.819, p = .70). The data support the conclusion that the ComPass2c program may have been effective in reducing 30-day all-cause readmission rates in Medicare FFS beneficiaries discharged from an academic hospital in New England. The program reached one third of the target Medicare FFS population. The implementation of post-discharge phone calls was similar to the original research but low for home visit and without change in patient activation. The Doctor of Nursing Practice (DNP) is in a unique leadership position to assess and determine the need for systems change at all levels of care, implement and evaluate evidence-based interventions in clinical practice, and facilitate interprofessional collaboration to improve quality of care. Future research should test transitional care interventions in subjects at risk for readmission who have historically been excluded, difficult to enroll and activate, and in receive care at safety net hospitals