Evaluation of a Multicomponent Care Transitions Program for High-Risk Hospitalized Older Adults

Peter J. Huckfeldt, Bernardo Reyes, Gabriella Engstrom, Qingnan Yang, Sanya Diaz, Samer Fahmy, Joseph G. Ouslander

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


OBJECTIVES: To test the effectiveness of a multicomponent care transition intervention targeted at hospitalized patients, aged 75 years and older, at high risk for hospital readmissions, return emergency department (ED) visits, and related complications. DESIGN: Implementation as a quality improvement program with propensity-matched preintervention and concurrent comparison groups over a 12-month period. SETTING: A 400-bed community teaching hospital. PARTICIPANTS: Patients, aged 75 years and older, admitted to non–intensive care unit beds who met specific high-risk criteria. The intervention group included 202 patients, and the concurrent and preintervention comparison groups included 4142 and 4592 patients, respectively. MEASUREMENTS: Primary outcomes were 30-day hospital readmissions and returns to the ED; 7-day readmissions and ED visits were secondary measures. RESULTS: Among the 202 patients enrolled in the “Safe Transitions for At-Risk Patients” (“STAR”) program, 37 (18.3%) were readmitted within 30 days, in contrast to 14.3% and 14.6% in the concurrent and preintervention comparison groups, respectively. Rates for 30-day return ED visits that did not result in hospitalization were 10.9% in the intervention group, and 7.2% and 7.9% in the comparison groups. STAR patients had greater 30-day ED use than patients in the preintervention comparison group (5.0 percentage points; 95% confidence interval = 0.8-9.3 percentage points; P =.020). Implementation challenges included suboptimal involvement of the participating hospital and post–acute care organizations and a relatively high proportion of patients who did not receive the intervention as planned, despite agreeing to participate before leaving the hospital. CONCLUSION: A multicomponent care transitions intervention targeting high-risk patients, aged 75 years and older, admitted to a community teaching hospital was not effective in reducing 30- or 7-day readmissions or return ED visits. Our implementation experience offers many lessons for future programs for similar high-risk geriatric populations. J Am Geriatr Soc 67:2634–2642, 2019.

Original languageEnglish (US)
Pages (from-to)2634-2642
Number of pages9
JournalJournal of the American Geriatrics Society
Issue number12
StatePublished - Dec 1 2019


  • care transitions
  • high-risk geriatric patients
  • hospital readmissions

PubMed: MeSH publication types

  • Evaluation Study
  • Journal Article
  • Research Support, Non-U.S. Gov't

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