The reduced rehospitalization rates reported herein
are comparable to those in previous investigations.
However, our study differs in 2 key areas. The first distinction
is in the level of intensity. In previous published
studies,30-33 the health care professionals assumed a primary
role in managing the care plan during the posthospitalization
transition period. In our study, the transition
coach assumed a supportive role and did not function as
a health care provider per se. In this less intense role, the
transition coach could manage more patients and there
was less potential for redundancy with existing health
care practitioners such as discharge planners, home
health care nurses, and case managers. The second distinction
concerns the duration of the intervention and
its potential to be sustained over time. The care transitions
intervention was designed not only to improve the
immediate transitions that patients and their caregivers
faced but also to provide them with skills and tools that
could be applied to future care transitions.