The Patient-Centered Transition Project for Dual Eligibles

Pilot Project

The Patient-Centered Transition Project for Dual Eligibles

Abstract: Dually eligible individuals, who qualify for both Medicare and Medicaid, are among the poorest and most vulnerable patients in the American health care system (1). As a result, these patients are particularly vulnerable to socioeconomic factors which can impede the successful transition from hospital to ambulatory care (2). They are more likely than other patients to lack timely primary care provider (PCP) follow-up, to return to the ED following hospital discharge, and to be readmitted to the hospital (3, 4).

Penn Medicine has partnered with Spectrum Health Services (SHS), a West Philadelphia community health center, to develop The Patient-Centered Transition (PaCT) Project. The PaCT Project utilizes trained CHWs to provide social support, navigation and advocacy to socioeconomically vulnerable patients who are being discharged from the The Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC). The CHWs, or PaCT Partners, will help patients to overcome the challenges of transition, including arranging primary care provider (PCP) follow-up, filling medication prescriptions and obtaining referrals to community-based social services. The PaCT Project is an established care transitions intervention that currently targets uninsured and Medicaid patients.

In this application, we propose a pilot randomized controlled trial of the Patient-Centered Transition (PaCT) Project in a dually eligible Medicare population. As our primary outcome, we will examine the effect of PaCT on rates of primary care follow-up. We will also examine the effect of PaCT on secondary outcome variables including patients’ satisfaction with the experience of transition, medication adherence, self-rated health, and ED revisit or inpatient readmission within 30 days after discharge.