The Department of Veterans Affairs Health System (VA) recently restructured its primary care delivery system so that nurse case managers can be used to help patients transition from the hospital to their homes. Building on this structure, a VA hospital in Wisconsin created the Coordinated-Transitional Care (C-TraC) program to facilitate smooth transitions and reduce repeated hospitalizations.

C-TraC is a telephone-based program specifically geared toward veterans at high risk for poor outcomes after hospitalization: those at least 65 years old and living alone or who were hospitalized on another occasion during the previous year or who have cognitive impairment.

Nurse case managers offered transition advice to veterans while they were still hospitalized, provided materials regarding red flags (signs of problems requiring attention), scheduled follow-up appointments, and provided contact information. Veterans also received medication counseling. Nurses then called each patient 48 to 72 hours after discharge to reinforce understanding of medication and the red flags. They made additional calls weekly for four weeks, until the follow-up appointment or until they were deemed unnecessary.

Data from the first six months of the program-before it was fully operational-were used to establish baseline values (103 patients) and compared with data from the subsequent 18 months, when C-TraC was in full effect (605 patients). Rates of repeated hospitalization within 30 days were 34% in the baseline group and 23% in the intervention group. Rehospitalization rates were consistently lower across the 18-month intervention period, ranging from 22% to 25%.

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