1. Wilcox, Diahann DNP, APRN, ACNP-BC
  2. McCauley, Paula S. DNP, APRN, ACNP-BC, CNE
  3. Delaney, Colleen PhD, RN, AHN-BC
  4. Molony, Sheila L. PhD, APRN, GNP-BC


Purpose: To evaluate the ComPass2c program by (1) effectiveness in reducing 30-day hospital readmissions, (2) reach of program into target population, and (3) implementation of key program elements.


Primary Practice Setting: An academic hospital in New England (John Dempsey Hospital).


Methodology and Sample: Retrospective analysis of Medicare fee-for-service (FFS) beneficiaries hospitalized at John Dempsey Hospital between May 1, 2012, and November 30, 2014.


Results: The program reached 34% of eligible Medicare FFS beneficiaries (n = 832; 61% female, mean age = 79 years). The unadjusted 30-day all-cause readmission rate decreased from 21% to 16.2% (p = .03). Implementation was high for postdischarge phone calls (89%) but low for home visits (34%). The mean change in patient activation scores following completion of the program was 0.15 (SD = 4.79), with no change in patient activation level, [chi]2 (6) = 3.82, p = .70.


Implications for Case Management Practice: The ComPass2c program was consistent with the philosophy and standards of case management practice. Case managers will want to utilize an evidence-based instrument with real-time information to identify patients at risk for 30-day readmission. A physical presence of ComPass2c coaches within the hospital enabled a strong hospital-community-based organization (CBO) partnership, facilitating the coordination, communication, and collaboration. Case managers will want to advocate for policy incentivizing hospital-CBO partnerships. Patient activation is essential; case managers may benefit from training in motivational interviewing to improve patient activation and outcomes. Additional research is needed to further elucidate and mitigate barriers to posttransition home visits and patient activation.