EFFECTIVE ADOPTION OF THE SUPPORTIVE COORDINATED TRANSITIONAL CARE PROGRAM IMPROVES END-OF-LIFE CARE FOR VETERANS - Abstract

Sep 28, 2026

Telephone-based Coordinated Transitional Care (CTrac) has been shown to reduce hospital readmissions, and this project implemented an adapted version, Supportive CTraC, to improve transitional and end-of-life care for veterans with advanced disease and life expectancy of ≤24 months. Using the Replicating Effective Programs framework, two nurse case managers adapted and implemented the program at one VA facility. Success targets included referrals to palliative care/hospice, hospice enrollment, new advance directives, and fewer acute care deaths; 203 veterans enrolled over 8 weeks.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Abstract

Program overview and objectives

Implementation approach

Outcomes and success criteria

768 Innovation in Aging, 2025, Vol. 9, No. S2 Abstract citation ID: igaf122.2610 EFFECTIVE ADOPTION OF THE SUPPORTIVE COORDINATED TRANSITIONAL CARE PROGRAM IMPROVES END-OF-LIFE CARE FOR VETERANS Lana Brown1, Hallie Keller1, Tanya Clayton1TaFarra Haney2, Ramona Rhodes3, Wanda Morrison1, and Jane Driver4, 1. Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, United States, 2. Eugene J. Towbin Healthcare Center, North Little Rock, Arkansas, United States, 3. UT Southwestern Medical Center, Dallas, Texas, United States, 4. VA Boston Healthcare System, Brockton, Massachusetts, United States The Coordinated Transitional Care (CTrac) program is a telephone-based, nurse-driven program shown to decrease hospital readmissions in acute care hospitals. This project implemented and evaluated an adapted version of CTraC, Supportive CTraC, developed at the Veteran Affairs (VA) Boston, to enhance the quality of transitional and end-of-life care for veterans with advanced disease and a life expectancy of ≤ 24 months. The Replicating Effective Programs framework, led by two registered nurse case managers, was used to adapt and implement the Supportive CTraC program at one VA facility. Program success was defined as > 30% of participating Veterans referred to palliative care/hospice, >30% enrolled in hospice, >30% with new Advance Directives, and fewer acute care deaths compared to the hospital average. Two-hundred three Veterans aged 43 to 96 enrolled in the program. Veterans were primarily male (96%), White (61%) or Black (34%), and non-Hispanic (97%) . About half (52%) were urban residents compared to rural (42%) or highly rural (5%). During the 8-week program, greater than 30% of Veterans completed an Advance Directive (57%), received a hospice/palliative care consult (48%), and enrolled in hospice (39%). By the end of the program, 135 (67%) Veterans had died. Of these, fewer died in acute care compared to the hospital average (20% vs. 36% ) . The remaining Veterans died at home (41%), in hospice/palliative care (36%), a nursing home or rehabilitation unit (2%), or an unknown setting (1%). The Supportive C-TraC program was successfully adapted and implemented, meeting all goals and facilitating positive end-of-life outcomes for Veterans.

FAQs

What is the Supportive CTraC program, and how was it delivered?

Supportive CTraC is an adapted, telephone-based program driven by nurses. It targets veterans with advanced disease and limited life expectancy to improve transitional and end-of-life care.

How did the project adapt and implement the program at a VA facility?

The Replicating Effective Programs framework guided the adaptation and implementation. Two registered nurse case managers led the process at one VA facility.

What outcomes were used to define program success?

Success was defined as more than 30% of participating veterans referred to palliative care/hospice, more than 30% enrolled in hospice, more than 30% with new advance directives, and fewer acute care deaths compared with the hospital average.

Sep 28, 2026

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