2 Scopus citations


The purpose of this pilot study was to assess the cost-effectiveness of four different doses (based on patients’ level of cognition and activation) of a home-based care transitions intervention compared with usual care at 2 and 6 months after hospital discharge to home for 126 adult patients with three or more chronic diseases. Health care utilization was measured, and a cost-effectiveness analysis was used to estimate incremental costs and quality-adjusted life-years associated with each intervention arm. At 6 months, results from this pilot study are very promising and support cost-effectiveness for Group 2-low cognition/high activation, Group 3-normal cognition/low activation, and Group 4-normal cognition/high activation patients. However, Group 1-low cognition/low activation needs a more intensive treatment than what was provided in the intervention, because of their low cognition and activation levels. Our intervention strategies provided to the groups would be scalable to a larger patient population and across different facilities.

Original languageEnglish (US)
Pages (from-to)622-642
Number of pages21
JournalWestern journal of nursing research
Issue number5
StatePublished - May 1 2017


  • care transitions
  • cost-effective analysis
  • multimorbid
  • self-management

ASJC Scopus subject areas

  • Nursing(all)

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