METHODS
STUDY SETTING AND DATES
The intervention was conducted in collaboration with a large
not-for-profit capitated delivery system that cares for more than
60 000 patients 65 years or older in Colorado. At the time the
study was initiated, the 30-day hospital readmission rate in this
delivery system for this particular population was approximately
15%. The delivery system contracts with a single hospital,
8 skilled nursing facilities, and a single home health care
agency. Patients received care from hospital-based physicians
(ie, hospitalists) during their hospital stays and, in general, from
a different team of health professionals in each posthospitalization
care setting. The study began September 1, 2002, and
concluded August 31, 2003. The institutional review board and
the Health Insurance Portability and Accountability Act authorities
of the participating health care system, contract hospital,
and University of Colorado Health Sciences Center approved
the study protocol.