Abstract 259: The Effects of Depression on BRIDGE Patients

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Jacob Carolan ◽  
Rachel Sylvester ◽  
Nathaniel Costin ◽  
Colin McMahon ◽  
Morgan Bradford ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Nurse Practitioner ◽  
Transitional Care ◽  
Care Program ◽  
Retrospective Data ◽  
Readmission Rates ◽  
History Of ◽  
Discharge Gap ◽  
History Of Depression

Background: Depression creates additional barriers to receiving transitional care. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program. We sought to determine if, 1) there was a difference in readmission rates of BRIDGE patients with depression (PWD) and those without depression (PWOD), and 2) if BRIDGE attendance lowered 30-day readmission rates in PWD. Methods: Retrospective data was abstracted for all patients referred to BRIDGE (June ’08 - Dec ’14). Readmission rates of PWD and PWOD were compared in both BRIDGE attenders and non-attenders. Results: Of 2446 patients, 577 (23.6%) had a history of depression. PWD were significantly younger (62.82 ± 14.04 v 66.17 ± 14.88, p<0.001), more likely to be female (55.6% v 39.1%, p<0.001), and less likely to attend their BRIDGE appointment (67.1% v 72.1%, p=0.010) than PWOD. Among BRIDGE attendees, PWD had significantly higher 60, 90, and 180 day readmission rates than PWOD (Table 1). Although 30 day readmissions were lower in PWD who attended BRIDGE, compared to PWD who did not attend BRIDGE, these results were not significant (10.5% v 12.6%, p=0.505), and this trend was not seen in 60, 90, and 180 day readmission rates. Conclusions: PWD are less likely to attend BRIDGE appointments and more likely to be readmitted. These results suggest that special attention needs to be given to PWD upon hospital discharge to ensure that proper transitional care is received and readmissions are avoided.

Abstract 256: Readmission Avoidability in Acute Coronary Syndrome Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Maria Souphis ◽  
Rachel Sylvester ◽  
Alison Wiles ◽  
Meghana Subramanian ◽  
William Froehlich ◽  
...  
Keyword(s):  
Transitional Care ◽  
Drug Effects ◽  
Care Program ◽  
Readmission Rates ◽  
Coronary Syndrome ◽  
History Of ◽  
Definition Of ◽  
Avoidable Readmission ◽  
Cancer Complications ◽  
Avoidable Readmissions

Background: Readmissions for ACS are common, costly, and potentially preventable. According to Medicare 13.4% of AMI admissions were followed by a rehospitalization within 15 days. A 2007 MedPAC report declared 76% of 30-day readmissions preventable. These rates are used as quality indicators despite lack of consensus on the definition of avoidable and unavoidable readmissions. We sought to define these terms and to analyze the effect of these definitions on 30-day outcomes. Methods: BRIDGE (Bridging the Discharge Gap Effectively) is an NP-led transitional care program for cardiac patients within 14 days of discharge. Retrospective data were abstracted on ACS patients readmitted before their appointments between 2008-2010. All readmissions were characterized as avoidable or unavoidable. Definitions were developed from the literature and in concert with senior cardiologists. Avoidable readmission was defined as being the result of a patient or provider issue that if managed may have prevented the admission. Unavoidable readmissions were defined as a patient in need of acute care. Avoidability status was further divided as related or unrelated to the index diagnosis. Results: Of 1188 BRIDGE referrals 304 (25.6%) experienced ACS events. In comparison to the total ACS population, patients readmitted before their BRIDGE clinic appointment (BC) (n=21, 6.9%) tended to be older, female, and were less likely to have a history of a cath or AMI (Table 1). In this study, 81% (n=17) of early readmissions were deemed unavoidable and most (n=14, 66.7%) were attributed to non-ACS issues or disease progression. These unavoidable readmissions included patients with cancer complications, chest pain, or other non-related diagnoses. Only 19% (n=4) of the readmissions were declared avoidable as a result of patient lack of adherence or provider issues such as adverse drug effects. Conclusion: The majority of early (before BC) readmissions following an index hospitalization for ACS patients referred to BRIDGE were unavoidable and unrelated to ACS. A clear discrepancy is seen between the 76% preventable readmissions in the MedPAC report and the 19% preventable readmissions in this study. Distinctions between unavoidable and avoidable readmissions should inform the utility of 30-day readmission rates as quality metrics.

Abstract 338: BRIDGE: A Post-Discharge Transitional Care Model in over 1600 Cardiac Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Rachel Sylvester ◽  
Minnie Bluhm ◽  
William Froehlich ◽  
Meghana Subramanian ◽  
Alison Wiles ◽  
...  
Keyword(s):  
Transitional Care ◽  
Care Program ◽  
Clinic Visit ◽  
Cardiac Patients ◽  
Post Discharge ◽  
Readmission Rates ◽  
Care Clinic ◽  
Charlson Comorbidity Score ◽  
History Of

Background: Current legislation imposes financial penalties for high 30-day readmissions for AMI. BRIDGE is a NP-led, post-discharge transitional care program for cardiac patients, aimed at ensuring prompt follow up (f/u; in 14 days) and care coordination. Herein we report the effect of BRIDGE on readmissions in over 1600 cases. Methods: Retrospective data was abstracted for patients referred to BRIDGE including demographics, comorbidities, medications, days to f/u, and 6-month outcomes by diagnosis. Results: Of 1955 patients referred to the BRIDGE clinic, 271 (13.9%) were excluded for adverse events prior to their visit (ED visit n=60, readmission n=193, or death n=14) or missing data (n=4). 1210 (71.9%) of patients from the remaining sample (n=1684) attended BRIDGE. Diagnoses included: ACS (n=462, 27.6%); angina (n=207, 12.4%); CAD (n=196, 11.7%); AFib (n=247, 14.7%); CHF (n=316, 18.9%); or other (n=256, 15.2%). With the exception of mental health disorders (35.4% v. 29.1%, p=.012) there were no baseline differences (including the Charlson Comorbidity Score) between non-attendees and attendees (Table 1). ACS attendees, compared to non-attendees, had a trend toward lower 30, 60, and 90 day readmission rates (Table 2). This was not observed for other diagnoses. Conclusions: A NP based transitional care clinic visit early post-discharge appears to reduce early readmissions for patients with an ACS, but in this study did not impact other cardiac conditions. Also, patients with a history of substance abuse or depression are significantly less likely to attend BRIDGE appointments. To avoid a lapse in care, these patients may need prompt f/u with their PCP or cardiologist to help reduce early readmissions.

scholarly journals Insights into hospital readmission patterns of atrial fibrillation patients

2020 ◽  
Vol 19 (6) ◽  
pp. 545-550
Author(s):  
Sherry Bumpus ◽  
Rachel Krallman ◽  
Colin McMahon ◽  
Ashwin Gupta ◽  
Daniel Montgomery ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Nurse Practitioner ◽  
Hospital Readmission ◽  
Transitional Care ◽  
Care Program ◽  
Index Hospitalization ◽  
Related Case ◽  
Patient Demographics ◽  
Baseline Characteristics ◽  
Discharge Gap

Introduction: Patients admitted to the hospital with atrial fibrillation have associated morbidity and mortality and incur significant costs. Data characterizing atrial fibrillation patients at high risk for readmission are scarce. We sought to inform this area by characterizing and categorizing unplanned readmissions of atrial fibrillation patients. Methods: Retrospective data were abstracted from the charts of patients discharged from 2008 to 2012 after an index hospitalization for atrial fibrillation and referred to the nurse practitioner-led transitional care program, Bridging the Discharge Gap Effectively. Unplanned readmissions were dichotomized as early (⩽30 days) or late (31–180 days) and further classified as either “atrial fibrillation/atrial fibrillation-related” (AF/AF-related), “Cardiac; not AF/AF-related,” or “Not cardiac-related.” Case classifications were adjudicated by a senior cardiologist. Patient demographics and readmission characteristics were then compared. Results: Of 255 patients, 97 (38.0%) had unplanned readmissions within 180 days of discharge; 45 (46.4%) were early and 52 (53.6%) were late. Atrial fibrillation and cardiac causes accounted for 68.9% ( n=31) of early readmissions and 65.4% ( n=34) of late. Patients with late readmissions were more likely to have diabetes (32.7% vs. 17.7%, p=.022) and higher CHA2DS2VASc scores (3.63 vs. 2.98, p=0.026) than those not readmitted. No other differences in baseline characteristics were seen within or between groups. The 30-day all-cause readmission rate in this sample was 17.6% ( n=45). Conclusion: Readmissions following hospital discharge for atrial fibrillation are common; approximately 50% of these readmissions are for reasons unrelated to atrial fibrillation. In order to reduce atrial fibrillation-related readmissions, further research is needed to characterize predictors of readmission and to develop effective transitional care interventions.

Abstract TP366: Significant Reduction in Readmission Using Transitions Nurse

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kiersten Espaillat ◽  
Paula Buckner
Keyword(s):  
Hospital Discharge ◽  
Transitional Care ◽  
Medical Center ◽  
Hospital Readmissions ◽  
Primary Diagnosis ◽  
Adult Patients ◽  
Care Coordinator ◽  
Readmission Rates ◽  
Before And After

In an effort to reduce early hospital readmissions, Vanderbilt University Medical Center (VUMC) implemented a transitional care coordinator (TCC) to provide careful coordinated follow up care for stroke patients after hospital discharge. The aim of this study is to compare all cause thirty- day readmission rates of adult patients with a primary diagnosis of stroke before and after the implementation of a stroke services TCC. All adult patients admitted to VUMC with a primary diagnosis of stroke; ischemic, hemorrhagic, and TIA; and readmitted within the first thirty days following hospital discharge between January-June of 2015, 2016, 2017, & 2018 were analyzed. Readmission data from 2015 & 2016, prior to the implementation of the TCC was compared to readmission data from 2017 & 2018, after the TCC was implemented. A total of 1911 charts were reviewed for the timeframe January-June of 2015-2018. In 2015 there were 369 stroke admissions and 120 (33%) were readmitted and in 2016 there were 474 stroke admissions and 112 (24%) readmissions, before the TCC role was implemented. In 2017 there were 540 stroke admissions and 62 (11%) were readmitted and in 2018 there were 528 stroke admissions and 74 (14%) readmissions, after the TCC role was implemented. Hospital readmissions were reduced significantly after implementing a TCC.

Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Caitlin Fette ◽  
Rachel Krallman ◽  
Colin McMahon ◽  
Daniel Montgomery ◽  
Jennifer Wang ◽  
...  
Keyword(s):  
Transitional Care ◽  
Care Program ◽  
Primary Diagnosis ◽  
Lower Mortality ◽  
Diabetic Patients ◽  
Post Discharge ◽  
Readmission Rates ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Discharge Outcomes

Background: Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE. Methods: Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients. Results: Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees. Conclusions: Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.

scholarly journals Implementation and Evaluation of a Team-Based Approach to Hospital Discharge Transition of Care

PRiMER ◽  
2021 ◽  
Vol 5 ◽  
Author(s):  
Matthew Van De Graaf ◽  
Hemal Patel ◽  
Brynn Sheehan ◽  
Jennifer Ryal
Keyword(s):  
Hospital Discharge ◽  
Transitional Care ◽  
Data Extraction ◽  
Hospital Readmissions ◽  
Cost Of Care ◽  
Phone Call ◽  
Readmission Rates ◽  
The Cost ◽  
Discharge Transition

Background: Transitional care management (TCM) programs guide patients from hospital discharge to outpatient follow-up with the goal to decrease hospital readmissions and the cost of care. In 2017, the department of primary care internal medicine (PCIM) at Eastern Virginia Medical Group implemented TCM. We aimed to evaluate the efficacy and self-sustainability of this TCM program. Methods: The TCM team contacted patients upon discharge to schedule the follow-up appointment. We coded patient contact as (1) no successful phone-call contact, patient did not attend appointment; (2) successful phone-call contact, patient did not attend appointment; and (3) patient attended appointment. We collected patient demographics, readmissions, and visit costs using manual chart review and electronic health record (EHR) data extraction. We conducted χ2 analysis, one-way analysis of variance, and unpaired t tests to assess associations between readmission rates or costs and TCM care. Results: Initial analysis did not indicate significant associations between readmission rates and level of TCM care at 30 (χ2=1.40, P=.50), 60 (χ2=5.48, P=.06), or 90 (χ2=4.23, P=.12) days or significant differences in patient charges at 30 (F[2,59]=2.85, P=.06), 60 (F[2,91]=2.00, P=.14), or 90 (F[2,126]=1.39, P=.25) days. Follow-up analysis indicated significant associations between readmission rates and any level of TCM care at 60 (χ2=5.40, P=.02) and 90 (χ2=4.21, P=.04) days, but not at 30 days (χ2=1.39, P=.28). Conclusions: Our TCM program review suggests that the benefits of transitional care extend beyond 30 days by decreasing readmission rates at 60 and 90 days after hospital discharge.

Abstract 357: Effect of an Early Nurse Practitioner Based Transitional Care Program on Atrial Fibrillation Readmissions

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Redah Z Mahmood ◽  
Sherry M Bumpus ◽  
Daniel G Montgomery ◽  
Eva Kline-Rogers ◽  
James B Froehlich ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Nurse Practitioner ◽  
Transitional Care ◽  
Tertiary Care ◽  
Care Program ◽  
Discharge Diagnosis ◽  
Chart Audit ◽  
Care Clinic ◽  
Coronary Syndrome ◽  
Ed Visits

Background: BRIDGE is a nurse practitioner (NP) based transitional care program for cardiac patients(pts) discharged from a large tertiary care health system. Attendance at the BRIDGE clinic has been shown to reduce early readmission and ED visits for acute coronary syndrome (ACS) pts. Little is known about causes of readmission for atrial fibrillation (AF) pts and whether an NP based program affects overall readmissions. Methods: Retrospective data on 1188 pts was abstracted from 2008 to 2010 for pts referred to BRIDGE. Early (30 day) readmission of pts with discharge diagnosis of AF underwent qualitative chart audit by a trained MD abstractor. When examining if BRIDGE affected readmissions, we excluded pts with ED visits/readmits prior to BRIDGE. Results: Median time to BRIDGE was 16 days. Of 1010 with complete data, 148 (15%) had a discharge diagnosis of AF; 110/148 (74%) AF pts attended BRIDGE. Thirty day readmission (30DR) for AF was 23% (34/148); 17/34 (57%) were sent to the ED by a MD or nurse. Attending BRIDGE had no effect on outcomes at all time points (table 1); 17 patients were readmitted before BRIDGE. Readmission at 6 months for AF was 41% for those who attended BRIDGE, 29% for those who did not (p=0.190). Table 2 details reasons for all 30DR in AF pts. Chart review demonstrated that all 30DR were appropriate, 83% (25/30) of non-elective readmissions were unavoidable, and of 5 potentially avoidable readmissions, 2 were due to patient non-compliance. Conclusions: 30-day readmission rates are high for pts recently discharged with a diagnosis of AF and most are unavoidable. A NP based transitional care clinic successful in reducing 30 day readmissions for ACS pts did not prevent either early or late readmissions in AF pts.

Abstract 339: Insights into Readmission Rates of Atrial Fibrillation Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Thomas Vasko ◽  
Rachel Sylvester ◽  
William Froehlich ◽  
Meghana Subramanian ◽  
Alison Wiles ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transitional Care ◽  
Care Program ◽  
Post Discharge ◽  
Readmission Rates ◽  
Bridge Program ◽  
Coronary Syndrome ◽  
Significant Difference ◽  
Care Models

Purpose and Background: Bridging the Discharge Gap Effectively (BRIDGE) is an NP-driven transitional care program for cardiovascular patients. It has demonstrated lower rates of readmission for patients with acute coronary syndrome who participated, but a similar benefit was not seen for atrial fibrillation (AF) patients. We sought to assess differences between AF patients who participated in the BRIDGE program and those who did not. Methods: Retrospective review of all patients referred to BRIDGE with a primary discharge diagnosis of AF was conducted (n=148). An equal number of BRIDGE attendees was randomly matched to non-attendees (n=36). Univariate techniques were used to compare groups. Results: Of 148 AF patients referred to BRIDGE, 84 (56.8%) attended BRIDGE, 36 (24.3%) saw cardiologists or PCPs for their first post-discharge follow-up, and 28 (18.9%) saw other providers or had unknown follow up. There was no significant difference in median time to follow up (12.5 days for attendees vs 9.0 days for non-attendees, p=0.503). Of the 72 patients reviewed, 17 (23.6%) were readmitted within 30 days (Table 1). Non-attendees were more likely (85.7% vs 40% p=0.134) to be readmitted with AF/related diagnoses as compared to attendees. More than half of 30-day readmissions for BRIDGE attendees were unrelated to AF (n=6, 60.0%). There was a trend toward greater incidence of comorbid CAD, HTN, CHF, or vascular disease among BRIDGE attendees, compared to non-attendees. Conclusion: Readmission patterns vary in AF patients; comorbid conditions play a role in early 30-day readmissions for AF patients despite adequate transitional care. NP-driven transitional care models, compared to traditional follow-up with a physician provider, may help identify additional issues related to comorbidities, leading to readmission. A larger sample is needed to better understand this dichotomy and to determine what measures can be taken to enhance the BRIDGE program for AF patients.

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