{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T01:13:13Z","timestamp":1787015593831,"version":"build-2736575974"},"reference-count":20,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2019,5,13]],"date-time":"2019-05-13T00:00:00Z","timestamp":1557705600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["agsjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J American Geriatrics Society"],"published-print":{"date-parts":[[2019,7]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVES<\/jats:title>\n                    <jats:p>Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30\u2010day hospital readmissions nationwide. The Coordinated\u2010Transitional Care (C\u2010TraC) program is a telephone\u2010based, nurse\u2010driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non\u2010VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C\u2010TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>DESIGN<\/jats:title>\n                    <jats:p>We used the Replicating Effective Programs model to guide the implementation. The C\u2010TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>SETTING<\/jats:title>\n                    <jats:p>The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>PARTICIPANTS<\/jats:title>\n                    <jats:p>Over its initial 14\u2009months, the program successfully enrolled 299 veterans with good fidelity to the protocol.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>MEASUREMENTS<\/jats:title>\n                    <jats:p>A total of 43 (15.8%) C\u2010TraC participants were rehospitalized within 30\u2009days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90\u2010day hospital admission, and discharge diagnosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>Participants were 54% less likely to be rehospitalized (odds ratio\u2009=\u2009.46; 95% CI\u2009=\u2009.24\u2010.89).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSION<\/jats:title>\n                    <jats:p>The program was financially sustainable. The total cost of care in the 30\u2010day postdischarge period was $1842.52 less per C\u2010TraC patient than per controls, leading the medical center to sustain and expand the program.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jgs.15978","type":"journal-article","created":{"date-parts":[[2019,5,13]],"date-time":"2019-05-13T11:05:31Z","timestamp":1557745531000},"page":"1502-1507","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":29,"title":["Coordinated\u2010Transitional Care for Veterans with Heart Failure and Chronic Lung Disease"],"prefix":"10.1111","volume":"67","author":[{"given":"Robyn L.","family":"Reese","sequence":"first","affiliation":[{"name":"University of New England College of Osteopathic Medicine  Biddeford Maine"},{"name":"Geriatric Research Education and Clinical Center VA Boston Healthcare System  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sherry A.","family":"Clement","sequence":"additional","affiliation":[{"name":"Department of Nursing VA Boston Healthcare System  Boston Massachusetts"},{"name":"Department of Medicine VA Boston Healthcare System  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sohera","family":"Syeda","sequence":"additional","affiliation":[{"name":"Department of Medicine VA Boston Healthcare System  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6136-8189","authenticated-orcid":false,"given":"Chelsea E.","family":"Hawley","sequence":"additional","affiliation":[{"name":"Geriatric Research Education and Clinical Center VA Boston Healthcare System  Boston Massachusetts"},{"name":"Department of Pharmacy VA Boston Healthcare System  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey S.","family":"Gosian","sequence":"additional","affiliation":[{"name":"Geriatric Research Education and Clinical Center VA Boston Healthcare System  Boston Massachusetts"},{"name":"Massachusetts Veterans Epidemiology Research and Information Center VA Boston Healthcare System  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shubing","family":"Cai","sequence":"additional","affiliation":[{"name":"Department of Public Health Services University of Rochester  Rochester New York"},{"name":"Geriatrics and Extended Care Data and Analyses Center Canandaigua VA Medical Center  Canandaigua New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laury L.","family":"Jensen","sequence":"additional","affiliation":[{"name":"Geriatric Research Education and Clinical Center William S. Middleton VA Hospital  Madison Wisconsin"},{"name":"Division of Geriatrics, Department of Medicine University of Wisconsin School of Medicine and Public Health  Madison Wisconsin"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy J.H.","family":"Kind","sequence":"additional","affiliation":[{"name":"Geriatric Research Education and Clinical Center William S. Middleton VA Hospital  Madison Wisconsin"},{"name":"Division of Geriatrics, Department of Medicine University of Wisconsin School of Medicine and Public Health  Madison Wisconsin"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jane A.","family":"Driver","sequence":"additional","affiliation":[{"name":"Geriatric Research Education and Clinical Center VA Boston Healthcare System  Boston Massachusetts"},{"name":"Massachusetts Veterans Epidemiology Research and Information Center VA Boston Healthcare System  Boston Massachusetts"},{"name":"Brigham and Women's Hospital and Harvard Medical School  Boston Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,5,13]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0803563"},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2016.0278"},{"key":"e_1_2_6_4_1","first-page":"43","article-title":"Measurement comparisons of the medical outcomes study and veterans SF\u201036 health survey","volume":"25","author":"Kazis LE","year":"2004","journal-title":"Health Care Financ Rev"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10729-014-9316-9"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.166.17.1822"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.281.7.613"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.2217\/cer-2018-0040"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2012.0366"},{"key":"e_1_2_6_10_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.13935"},{"key":"e_1_2_6_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2017.04.008"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.13315"},{"key":"e_1_2_6_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/jrh.12212"},{"key":"e_1_2_6_14_1","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-2-42"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e31827da95a"},{"key":"e_1_2_6_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1553-7250(13)39051-5"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.13702"},{"key":"e_1_2_6_18_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2007.106"},{"key":"e_1_2_6_19_1","doi-asserted-by":"publisher","DOI":"10.2215\/CJN.00580118"},{"key":"e_1_2_6_20_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-018-3771-9"},{"key":"e_1_2_6_21_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2018.17933"}],"container-title":["Journal of the American Geriatrics Society"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Fjgs.15978","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jgs.15978","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/jgs.15978","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/agsjournals.onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jgs.15978","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T15:18:07Z","timestamp":1762183087000},"score":1,"resource":{"primary":{"URL":"https:\/\/agsjournals.onlinelibrary.wiley.com\/doi\/10.1111\/jgs.15978"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,5,13]]},"references-count":20,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2019,7]]}},"alternative-id":["10.1111\/jgs.15978"],"URL":"https:\/\/doi.org\/10.1111\/jgs.15978","archive":["Portico"],"relation":{},"ISSN":["0002-8614","1532-5415"],"issn-type":[{"value":"0002-8614","type":"print"},{"value":"1532-5415","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,5,13]]},"assertion":[{"value":"2018-12-03","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2019-03-29","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2019-05-13","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}