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.

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.

scholarly journals Transitional care from the hospital to the home in heart failure: implementation of best practices

2022 ◽  
Vol 75 (1) ◽  
Author(s):  
Michele Nakahara-Melo ◽  
Ana Paula da Conceição ◽  
Diná de Almeida Lopes Monteiro da Cruz ◽  
Vilanice Alves de Araújo Püschel
Keyword(s):  
Heart Failure ◽  
Best Practices ◽  
Hospital Discharge ◽  
Transitional Care ◽  
Self Care ◽  
Telephone Contact ◽  
Before And After ◽  
Care Practices ◽  
Implementing Strategies

ABSTRACT Objectives: Assess the compliance of the implementation of better evidence in the transitional care of the person with heart failure from the hospital to the home. Methods: Evidence implementation project according to the JBI methodology in a cardiology hospital in São Paulo. Six criteria were audited before and after implementing strategies to increase compliance with best practices. 14 nurses and 22 patients participated in the audits. Results: In the baseline audit, compliance was null with five of the six criteria. Strategies: training of nurses; reformulation of the hospital discharge form and guidance on self-care in care contexts; and making telephone contact on the 7th, 14th and 21st days after discharge. In the follow-up audit, there was 100% compliance with five of the six criteria. Conclusion: The project made it possible to increase the compliance of transitional care practices in people with heart failure with the recommendations based on the best evidence.

scholarly journals Burden of Hospital Readmissions for Venous Thromboembolism Among Patients with Cancer

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 365-365
Author(s):  
Alpesh J. Amin ◽  
Steven Deitelzweig ◽  
Jay Lin ◽  
Melissa Lingohr-Smith ◽  
Brandy Menges ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Hospital Readmission ◽  
Hospital Readmissions ◽  
Primary Diagnosis ◽  
Post Discharge ◽  
Vte Prophylaxis ◽  
Patients With Cancer ◽  
Diagnosis Codes ◽  
The Mean

Abstract Background: Cancer or history of cancer are important risk factors for hospitalized patients to develop venous thromboembolism (VTE), manifesting as deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Patients hospitalized for cancer are thus at risk for VTE. However, several studies show that VTE prophylaxis in these patients is challenging and underutilized, with almost 70% of patients with cancer not receiving any VTE prophylaxis as evaluated by our previous analysis. Therefore, this patient population is at risk of recurrent VTE and re-hospitalization. The clinical and economic burden of VTE-related hospital readmissions among these patients is not well understood in the real-world setting. The goal of this retrospective study was thus to analyze the frequency and associated cost of VTE-related hospital readmissions among patients with cancer in the US. Methods: Patients hospitalized for acute medical illness, including cancer, based on the primary hospital discharge diagnosis codes were identified from the MarketScan databases between 7/1/2011 and 3/31/2015. Eligible patients were ≥40 years and required to have continuous insurance enrollment in the 6 months prior to initial (index) hospitalizations (baseline period) and in the 6 months after hospital discharge (follow-up period). The study endpoints included the proportion of patients with VTE as either the primary or any position (VTE-related) of discharge diagnosis codes among hospital readmissions during the follow-up period, and the associated costs for VTE-related or primary VTE readmissions. Results: Of the whole study population of acute medically ill patients (n=12,785; mean age: 68.3 years; 51.6% female), 15.7% (n=2,002) were hospitalized for cancer; the mean age was 63.4 years (62% were <65 years) and 49.1% were female. Among patients with cancer, 3.9% had a VTE-related hospital readmission in the 6 months following hospital discharge, of which 51.3% were for a primary diagnosis of VTE (Table). The frequency of readmissions for patients with cancer were the highest among all medical illnesses investigated in this study (acute heart failure, infectious diseases, ischemic stroke, respiratory diseases, and rheumatic diseases). Over one-quarter (28.2%) of the VTE-related hospital readmissions occurred within the first 30 days of post-discharge (Table). For VTE-related readmissions, the mean length of hospital stay (LOS) was 7.6 days and the mean total cost for a hospital readmission was $35,012. For primary VTE readmissions, the mean LOS was 5.2 days and the mean total cost of a readmission was $19,961; for readmissions with a primary diagnosis of DVT, PE, and DVT/PE, mean total costs were $12,968, $13,029, and $41,574, respectively. Conclusions: In this real-world study, many patients hospitalized for cancer experienced a VTE event requiring re-hospitalization, which was the highest proportion of readmitted patients among acute medical illnesses analyzed in this study, with almost 30% readmitted within 30 days of post-discharge. Total costs of readmissions were substantial, as high as $41K for resubmissions due to primary diagnosis of DVT/PE. Improvement in VTE prophylaxis for patients with cancer may reduce the risk and frequency of VTE, and thus hospital readmissions, reducing the clinical and economic burden of VTE in this patient population. Sponsorship: Portola Pharmaceuticals Disclosures Amin: UC Irvine: Employment; Portola: Consultancy; BMS: Consultancy; Pfizer: Consultancy. Deitelzweig:Ochsner Health System: Employment; Portola: Consultancy, Research Funding, Speakers Bureau; BMS: Consultancy, Research Funding, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; Boeringer Ingelheim: Consultancy. Lin:Bristol-Myers Squibb: Consultancy; Novosys Health: Employment. Lingohr-Smith:Novosys Health: Employment. Menges:Novosys Health: Employment. Neuman:Portola Pharmaceuticals: Employment.

scholarly journals Booking the Appointment: A Strategy to Reduce Readmissions in Heart Failure Patients

2013 ◽  
Author(s):  
Lindsey Moran
Keyword(s):  
Heart Failure ◽  
Hospital Discharge ◽  
Acute Care Hospital ◽  
The United States ◽  
Primary Diagnosis ◽  
Care Hospital ◽  
Chart Audit ◽  
Readmission Rates ◽  
June July

Heart failure (HF) is a chronic condition that is the cause for many hospitalizations in the United States. Hospital readmission is a common problem in many chronic conditions, especially heart failure. The purpose of this research was to determine if scheduling a follow-up appointment with a primary care provider (PCP) or cardiologist prior to hospital discharge decreases 30-day readmission rates in patients with a primary diagnosis of HF. A quasi-experimental, two-group study was performed at The Miriam Hospital, a 247-bed acute care hospital, with a sample of 60 patients. A retrospective chart audit was performed to determine if 30-day readmission rates were lower in those HF patients who had a follow-up appointment booked prior to hospital discharge than those who did not have the appointment booked. Charts were reviewed for patients discharged during June, July, August and September 2012. Basic descriptive statistics were performed as well as differences between groups. Thirty-day readmission rates were lower for those who had a follow-up appointment booked (22.58%) compared those who did not have an appointment booked (31.03%). The 30-day readmission rate for those who had an appointment with a PCP was higher than those who followed up with a cardiologist (33.33% versus 7.69%). These findings suggest that booking a follow-up appointment for HF patients with a cardiologist prior to hospital discharge may help to decrease 30-day readmission rates. This simple intervention can be performed by nonclinical, administrative staff and could save hospitals money if even one HF readmission were prevented.

scholarly journals Strategies to implement the safe hospital-community transition and mitigate hospital readmissions

2021 ◽  
Vol 11 (1) ◽  
pp. 2-3
Author(s):  
Óscar Manuel Ramos Ferreira ◽  
Cristina Lavareda Baixinho
Keyword(s):  
Hospital Discharge ◽  
Elderly Population ◽  
Hospital Readmissions ◽  
The Elderly ◽  
Health Problems ◽  
Readmission Rates ◽  
Interpersonal Conflicts ◽  
Sick People ◽  
Community Transition

Transition is defined as a journey made by a person between two relatively stable moments. This experience is lived over a certain period and is characterized by the appearance of changes that cause imbalances, doubts, disorganization, and interpersonal conflicts. Therefore, hospital discharge is a multiple transition (from health-illness, but also situational) from the hospital to the community, through which all individuals who have serious health problems have required hospitalization go through. If such a transition is made early and without proper planning, there is a serious risk that the discharged person will be readmitted in the short or medium-term.Recently, readmission rates have been increasing, particularly among the elderly population. This increase does not seem to be due to the severity of the diagnosis, but the comorbidities of which sick people are carriers.

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.

Abstract 15829: Temporal Characteristics of Intra-thoracic Impedance Before and After Heart Failure Hospitalizations in a Large Real-world Population of Patients With Cardiovascular Implanted Electronic Devices

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Shantanu Sarkar ◽  
Jodi L Koehler ◽  
Eddy Warman
Keyword(s):  
Real World ◽  
Electronic Devices ◽  
Primary Diagnosis ◽  
Implantable Devices ◽  
World Population ◽  
Inclusion Criteria ◽  
Temporal Characteristics ◽  
Before And After ◽  
Intrathoracic Impedance

Introduction: Intrathoracic impedance (IMP), measured in ICD/CRTD implantable devices, is a measure of intravascular blood volume and have been shown to correlate with intracardiac pressures. We investigated the temporal characteristics of IMP before and after HF events (HFE) in a large real-world cohort of patients (pts) with ICD/CRTD devices. Methods: We linked Optum© deidentified EHR dataset during the period from 2007-2017 to the Medtronic CareLink data warehouse. Pts with ICD/CRTD implants with IMP measurements were included. HFE was defined as an inpatient, ED, or observation unit stay with primary diagnosis of HF and IV diuretics administration. Temporal average of IMP measurement across all pts in the 60 days pre and post HFE were compared for HFE with and without readmission for HF within 60 days and in pts with no HFE. Results: A total of 17,886 pts with 1.8±1.2 years of follow-up met inclusion criteria. The average age was 66.6 ±12.3 years, with 72% being males, and 51% with ICD devices. A total of 1174 pts had 1425 HFE with no readmission and 282 pts had 295 HFE which were followed by readmission. A total of 17,839 pts had no HFE over 86,858 follow-up months. The average IMP during HFE, with and without readmission, and in pts with no HFE are shown in Fig. IMP decreases over a period of time prior to HFE and recovers due to treatment during HFE. The average IMP across all patients was lower on all 60 days pre and post HFE with readmission compared to HFE with no readmission (p<0.001) and both were lower compared to follow-up period with no HFE (p<0.001). The IMP recovers less often after HF events which are followed by readmission within 60 days compared to HF events with no readmission. Conclusions: In a large real-world population of pts with ICD/CRTD devices, on an average IMP reduces prior to and recovers during HFE. IMP was lower before and after HFE with readmission compared to HFE with no readmission. Readmission is more likely in pts with smaller impedance recovery after HF events.

scholarly journals Reducing Preventable Readmissions in a Neurosurgical Patient Population at an Academic Medical Center

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Shayan Moosa ◽  
Lindsay Bowerman ◽  
Ellen Smith ◽  
Mindy Bryant ◽  
Natalie Krovetz ◽  
...  
Keyword(s):  
High Risk ◽  
Patient Population ◽  
Medical Center ◽  
Academic Medical Center ◽  
Readmission Rates ◽  
Academic Medical ◽  
Neurosurgical Patient ◽  
Neurosurgical Patients ◽  
Significant Difference

Abstract INTRODUCTION Hospital readmissions are extremely costly in terms of time and resources and negatively impact patient safety and satisfaction. In this study, we performed a Pareto analysis of 30-day readmissions in a neurosurgical patient population in order to identify patients at high-risk for readmission. Using this information, we implemented a new practice parameter with the goal of reducing preventable readmissions. METHODS Patient characteristics and causes for readmission were prospectively collected for all neurosurgical patients readmitted to an academic medical center within 30 d of discharge between July and October 2018. A program was then initiated where postoperative neurosurgical spine patients were contacted by phone at standardized intervals before their 2-wk follow-up appointment, with the purpose of more quickly addressing surgical concerns and/or coordinating care for general medical issues. Finally, 30-d readmission rates were compared between the initial 4-mo period and January 2019 through April 2019. RESULTS Prior to intervention, the largest group of readmitted patients included those who had undergone recent spinal surgery (16/47, 34%). Among spine readmissions during this time, 47% were readmitted before their two-week follow-up appointment, 67% lived over 50 miles from the medical center, and 40% were Medicare-insured. There was a statistically significant difference in the mean rate of spine readmissions per month in the periods before (7.0%) and after (3.0%) the program onset (P = .029, 57% decline). The total number of surgically and medically related spine readmissions decreased between the pre- and postintervention periods from 10 to 3 (70%) and 3 to 1 (67%), respectively. CONCLUSION Our data suggests that a large number of neurosurgical readmissions may be prevented by the simple process of early follow-up and consistent communication via telephone. Readmission rates may be further reduced by standardizing the coordination of postoperative general medical follow-up and providing thorough wound care teaching for high-risk patients.

33 Effectiveness of Caregiver-oriented Transitional Care Program (CTCP) in Promoting Preparedness of Caregivers for Home Care of Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S23-S24
Author(s):  
Jun Jun A Dualan
Keyword(s):  
Home Care ◽  
Hospital Discharge ◽  
Wound Dressing ◽  
Transitional Care ◽  
Teaching Method ◽  
Medication Administration ◽  
Instructional Materials ◽  
Burn Patients ◽  
Before And After ◽  
Burn Units

Abstract Introduction Unpreparedness of caregivers of burn patients can result to several complications at post-discharge period (Zwicker, 2010; AHRQ, 2012). Some burn centers in resource-scarce countries had documented several burn morbidity and mortality that occurred post hospital discharge. Psychological conditions, contractures, infection and even death are just some of the complications. One of the current trends in burns involves sending patients home with a burn dressing and following them up as outpatients for wound inspection. This could significantly reduce cost of hospitalization with shortened hospital stay and allows burn units to accommodate the overflow of acute and complex cases for admission. Although there are advantages in early discharge, this approach requires a change in the health teaching method and contents since hospital-to-home transition is expedited. Considering this dilemma, the investigator developed the CTCP to address the gap in transitional care of burns. This study aimed to compare the preparedness of caregivers before and after CTCP; and compare caregivers’ handwashing competency, wound dressing competency and medication administration hassle before and after CTCP. Methods One-group pre-and-posttest quasi-experimental design was used to study thirty adult caregivers of burn patients that were recruited via convenience sampling in a burn center between November 2017 to March 2018. CTCP was conducted in three sessions with the aid of videos and written instructional materials. Caregivers were evaluated in terms of preparedness (primary outcome) and handwashing competency, wound dressing competency and medication administration hassle (secondary outcomes). All measurement instruments were content valid and reliable. Results At alpha 0.05, data analysis revealed statistically significant results supporting the use of CTCP. Preparedness (p&lt; 0.001), handwashing competency (p&lt; 0.001), wound dressing competency (p&lt; 0.001) and medication administration hassle (p&lt; 0.001) improved after receiving the structured teaching intervention. Conclusions The study supported the relevance of the interventions to prepare caregivers for home care of burn patients to help prevent potential complications after hospital discharge. This is therefore recommended to be adapted by burn units that recognize primary caregivers as extended team members. Applicability of Research to Practice Since there is a limited evidence in nursing discharge education programs specific to burns, the results generated from this study can help practitioners effectively prepare caregivers for home care of burn patients as educational intervention is supported with strategies that increase learning retention.

scholarly journals Reduction of 30-Day Hospital Readmissions after Patient-centric Telephonic Medication Therapy Management Services

2016 ◽  
Vol 51 (11) ◽  
pp. 907-914 ◽  
Author(s):  
Daryl E. Miller ◽  
Teresa E. Roane ◽  
Karen D. McLin
Keyword(s):  
Hospital Discharge ◽  
Hospital Readmission ◽  
Hospital Readmissions ◽  
Medication Therapy Management ◽  
Medication List ◽  
Readmission Rates ◽  
Therapy Management ◽  
Medication Therapy ◽  
Hospital Readmission Rates ◽  
Significant Difference

Background Transitional care programs are a growing topic in health care systems across the country, with a focus on achieving a reduction in hospital readmissions and improving patient and medication safety. Numerous strategies have been employed and studied to determine successful approaches to patient transition from the hospital setting to the home setting. Pharmacist-mediated postdischarge telephonic outreach has demonstrated decreased hospital readmission rates in multiple hospital systems. Objective To evaluate the effectiveness of pharmacist-facilitated telephonic medication therapy management (MTM) services on reducing hospital readmissions. Methods A retrospective chart analysis ( n = 314) was performed for patients who received MTM services following hospital discharge between February 23, 2014 and July 4, 2014. The primary outcome was 30-day all-cause readmission. The secondary outcomes were identification of pharmacist interventions for and recommendations about medication-related problems and discrepancies found between the patients' reported medication list and the hospital discharge medication list. Results The data revealed no statistically significant difference in hospital readmission rates between the intervention and control groups (odds ratio, 1.04; 95% CI, 0.68–1.60). Pharmacists intervened on 189 medication-related problems via facsimile to the prescriber (35.7% of charts), contacted prescribers by phone for 23 medication-related or health-related issues, and identified 823 medication list discrepancies (78.34% of charts). Conclusion Although the provision of telephonic MTM services by pharmacists did not result in an improvement in the readmission rate during this study period, pharmacists were able to intervene on numerous medication-related problems and medication list discrepancies.

Sign in / Sign up

Export Citation Format

Share Document