Implementing an Emergency Department to Home Care Transition Intervention

Emergency Room (ER) patients with limited health literacy who agree to participate in this
study will be asked to complete a survey about how they feel about their health care and how
easy or hard it is to get health care. Patients will also be asked for some basic
information about themselves like their age, race, gender, employment and marital status,
their overall health and health conditions. The research team will review the electronic
medical record for information about participants' health conditions and how sick the ER
nurse thought the patient was when they came to the ER.

Patients who decide to participate in the study will also be randomly assigned, much like
the flip of a coin to receive either a new way of educating patients (the Care Transition
Intervention) or normal care. This means:

If patients receive the new way of educating, a coach will visit the patient at home one
time one or two days after the ER visit to see how the patient is doing. He/she will talk
with the patient about following up with a regular, personal doctor and symptoms to look out
for. He/she will help the patient understand their medicines and help the patient make a
personal health record. The coach will also tell the patient about the Area Agency on Aging,
also called Elder Options. If the patient receives normal care, the patient will not receive
a visit from the coach or hear about the Area Agency on Aging but will be given discharge
instructions from the ER nurse and doctor.

If the patient receives the new way of educating (the Care Transition Intervention), the
coach will call the patient at least 3 times after the ER visit. He/she will talk with the
patient about the same items listed above. If the patient receives normal care, the coach
will not call. The patient has a 1 in 2 chance of receiving the new way of educating and a 1
in 2 chance of receiving normal care.

All patients will be asked to complete a phone survey 31-60 days after their ER visit. This
survey will ask the patient about follow up with a regular, personal doctor. The survey will
also ask the patient how they feel about their health care and how easy or hard it is to get
health care after an ER visit.

Some patients will also be asked if they are willing to give a separate interview. The study
doctor will ask about what happened when you were in the ER. She will also ask about how
things went after your ER visit. If the coach contacted you, she will ask about this as
well. This interview will be audio recorded.

Inclusion Criteria:

- 60 years of age or older,

- are on Medicare,

- are community dwelling,

- reside within the geographical area defined by specific zip codes (to enable home
visits),

- have a working telephone, and

- have at least one of the following conditions documented in their medical record:
congestive heart failure, chronic obstructive pulmonary disease, coronary artery
disease, diabetes, stroke, pneumonia, medical and surgical back conditions
(predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac
arrhythmias, deep venous thrombosis, pulmonary embolism, peptic ulcer disease or
hemorrhage.

- health literacy will be assessed with the 66-item Rapid Estimate of Adult Literacy in
Medicine (REALM)(Davis, Crouch et al.)

Exclusion Criteria:

- current diagnosis of psychosis,

- active substance abuse related to alcohol or drugs,

- cancer,

- dialysis

- history of organ transplantation,

- have dementia without a live-in caregiver, or

- in hospice care,

- reside outside the defined geographical area,

- reside in a skilled nursing facility, or

- assisted living will be excluded