Does Care Management Help Patients Recover from a Serious Injury? [Internet]

Excerpt

Background: Currently, high-quality patient-centered care is not the standard of care throughout US trauma care systems. Injured trauma survivors treated in trauma care systems frequently receive fragmented care that is not coordinated across hospital, emergency department (ED), outpatient, and community settings. Postinjury care is frequently not individualized to integrate the patient's most pressing posttraumatic concerns and preferences into medical decision-making.

Objectives: The aim of this randomized comparative effectiveness trial was to compare 2 approaches to the delivery of patient-centered care for hospitalized injured trauma survivors: a novel patient-centered care transition service delivery model vs enhanced usual care that included notifications to nurses of trauma survivors' postinjury concerns.

Methods: The care transition intervention included a Master's-level social worker who first elicited and then addressed each injured trauma survivor's posttraumatic concerns; whenever possible, the social worker attempted to integrate the trauma survivor's concerns and preferences into medical decision-making, and problem solve with the patient. The intervention team provided 24-hour cell phone contact, 7 days a week, that included text messaging services aimed to enhance care coordination and reduce ED visits. The primary outcome examined was the severity and domain of patient-identified postinjury concerns. Other primary outcomes examined included posttraumatic stress disorder and depressive symptom severity. Secondary outcomes examined included physical function, automated statewide health service use, satisfaction with the physical and emotional aspects of care, and injury risk behaviors. Regression analyses assessed intervention and control group outcome differences over time.

Results: Of the 171 patients, motor vehicle, pedestrian, or bicycle-related crashes represented approximately 50% of the injuries. Other events (eg, falls, work injuries) represented approximately 36% of injuries. More than 80% patient follow-up was attained at each time point. Concerns elicited from patients spanned physical health, work/finance, social, psychological, medical, and legal domains. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns when compared with controls longitudinally (Wald χ² = 11.29; P = .01) and at the 6-month study time point (Control [C] = 74%, Intervention [I] = 53%; Fisher exact test, P = .02). Comparisons of ED use data yielded clinically significant differences at the 6-month time point (1 or more 3- to 6-month ED visits; C = 30.2%, I = 16.5%; relative risk [95% CI], C vs I = 2.00 [1.09-3.70], P = .03) that did not achieve significant differences over time when compared with baseline (F3,507 = 2.24, P = .08). The intervention did not significantly affect other symptomatic, risk behavior, or functional outcomes.

Conclusions: The investigation found that patients who received the intervention had a clinically and statistically significant reduction in the percentage of any severe postinjury concerns expressed over the course of the 6 months after injury hospitalization. Clinically important ED health service use reductions were observed, but the intervention did not affect other symptomatic or functional outcomes. These initial findings are provocative and could lead to further investigation to develop a body of knowledge that would inform sustainable American College of Surgeons' clinical guideline requirements for US trauma care systems.

Limitations and Subpopulation Considerations: Because this was a multifaceted intervention, the investigation did not yield information about which components of the treatment were effective in targeting specific outcomes. No analyses were conducted to examine lasting intervention effects. The investigation did not find substantial age, ethnoracial, or traumatic brain injury group differences in treatment outcomes.