Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too

Jing Li, Jessica Miller Clouser, Jane Brock, Terry Davis, Brian Jack, Carol Levine, Glen P. Mays, Brian Mittman, Huong Nguyen, Joann Sorra, Arnold Stromberg, Gaixin Du, Chen Dai, Akosua Adu, Nikita Vundi, Mark V. Williams

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Background: As health systems shift toward value-based care, strategies to reduce readmissions and improve patient outcomes become increasingly important. Despite extensive research, the combinations of transitional care (TC) strategies associated with best patient-centered outcomes remain uncertain. Methods: Using an observational, prospective cohort study design, Project ACHIEVE sought to determine the association of different combinations of TC strategies with patient-reported and postdischarge health care utilization outcomes. Using purposive sampling, the research team recruited a diverse sample of short-term acute care and critical access hospitals in the United States (N = 42) and analyzed data on eligible Medicare beneficiaries (N = 7,939) discharged from their medical/surgical units. Using both hospital- and patient-reported TC strategy exposure data, the project compared patients “exposed” to each of five overlapping groups of TC strategies to their “control” counterparts. Primary outcomes included 30-day hospital readmissions, 7-day postdischarge emergency department (ED) visits and patient-reported physical and mental health, pain, and participation in daily activities. Results: Participants averaged 72.3 years old (standard deviation =10.1), 53.4% were female, and most were White (78.9%). Patients exposed to one TC group (Hospital-Based Trust, Plain Language, and Coordination) were less likely to have 30-day readmissions (risk ratio [RR], 0.72; 95% confidence interval [CI] = 0.57–0.92, p < 0.001) or 7-day ED visits (RR, 0.72; 95% CI, 0.55–0.93, p < 0.001) and more likely to report excellent physical and mental health, greater participation in daily activities, and less pain (RR ranged from 1.11 to 1.15, p < 0.01). Conclusion: In concert with care coordination activities that bridge the transition from hospital to home, hospitals’ clear communication and fostering of trust with patients were associated with better patient-reported outcomes and reduced health care utilization.

Original languageEnglish
Pages (from-to)40-52
Number of pages13
JournalJoint Commission Journal on Quality and Patient Safety
Issue number1
StatePublished - Jan 2022


  • Care transitions
  • Hospital Readmissions
  • Patient Communication
  • Trust


Dive into the research topics of 'Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too'. Together they form a unique fingerprint.

Cite this