Transitional Care Model Evaluation 2020

The study is a randomized controlled trial to estimate the effects of the transitional care model (TCM) on hospital admissions and patients' experience during the year following the patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will be the coordinating center for the implementation. The study will be conducted in three large health systems spread throughout the U.S., drawing patients from seven hospitals in those systems. Eligible patients are older adults (age 65 and older) admitted to a participating hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia (PNA). The evaluation will be conducted by Mathematica.

Inclusion Criteria: * Age 65 years and older * Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis * English and non-English speaking, able to respond to questions * Reachable by telephone after discharge * Resides within the geographic service area * Consent to participation Exclusion Criteria: * Enrolled in Medicare's Hospice or End-Stage Renal Disease programs * Presence of active and untreated psychiatric conditions (ICD10: F10-F29) * Long-term care resident * Undergoing active cancer treatment * Currently enrolled in another RCT