Experimental Design
The Hospital Transition Program targets patients in three West Virginia hospitals that have been identified as having a high probability of hospital readmission. The three hospitals include: Wheeling Hospital (Wheeling, WV), Cabell-Huntington Hospital (Huntington, WV ), and St. Mary’s Hospital (Huntington, WV).
Eligible patients must meet the following criteria:
- Adults aged 18 and above
- Currently admitted at Wheeling, Cabell-Huntington, or St. Mary’s Hospital
- Covered by Medicare or Medicaid (including dual eligibles)
- Resides in a ZIP code within 15 miles of the admitting hospital.
- Readmission risk score (probability) at time of admission in top quartile within hospital. A patient’s readmission risk score is a probability of readmission based on a patient’s initial diagnosis, comorbidities, previous hospital admissions, and social determinants of health.
Patients will be excluded if they meet any of the following criteria:
- Already a subject in the RCT (treatment or control)
- Deceased or discharged prior to triage or recruitment
- Discharged to a long-term care facility
- Homeless
- Index hospitalization is for a child birth
Each afternoon, the participating hospitals’ management information systems will flag any newly-admitted patients that meet the eligibility criteria established above. Patients will be ordered sequentially based on their admission to the hospital; for each two new patients that are added, one will be randomly assigned to a CCWVa case manager who will then contact the patient in the hospital, outline the services offered by the HTP, and if they agree, consent the patient to receive services.