Diagnosis-group-specific transitional care program recommendations for 30-day rehospitalization reduction

With changing health care, progressive care nurses are working in diverse practice settings to meet patient care needs. Progressive care is practiced along the continuum from the intensive care unit to home. The benefits of early progressive mobility are examined with a focus on the interdisciplinary collaboration for care in a transitional care program of a skilled nursing facility. The program’s goals are improved functional status, self-care management, and home discharge with reduced risk for hospital readmission. The core culture of the program is interdisciplinary collaboration and team partnership for care of patients and their families.

Download Full-text

Poster 144: The Institution of a Rehabilitation Transitional Care Program Can Significantly Decrease Readmission Rates to the Acute Care Hospital from The Acute Inpatient Rehabilitation Unit

PM&R ◽

10.1016/j.pmrj.2017.08.087 ◽

2017 ◽

Vol 9 ◽

pp. S179-S179

Author(s):

Annamaria L. Dunn ◽

Marianne Boylston ◽

Nurse Practitioner ◽

Alessandra Dunn

Keyword(s):

Acute Care ◽

Transitional Care ◽

Acute Care Hospital ◽

Inpatient Rehabilitation ◽

Care Program ◽

Care Hospital ◽

Readmission Rates ◽

Rehabilitation Unit

Download Full-text

Abstract 256: Readmission Avoidability in Acute Coronary Syndrome Patients

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.256 ◽

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.

Download Full-text

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

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.097 ◽

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.

Download Full-text

The effect of a pharmaceutical transitional care program on rehospitalisations in internal medicine patients: an interrupted-time-series study

BMC Health Services Research ◽

10.1186/s12913-019-4617-9 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 3

Author(s):

Fatma Karapinar-Çarkıt ◽

Sander D. Borgsteede ◽

Marjo J. A. Janssen ◽

Marlies Mak ◽

Nimet Yildirim ◽

...

Keyword(s):

Time Series ◽

Usual Care ◽

Medication Reconciliation ◽

Primary Outcome ◽

Transitional Care ◽

Care Program ◽

Interrupted Time Series ◽

Time Series Study ◽

Hospital Visits ◽

Series Study

Abstract Background Medication errors at transition of care can adversely affect patient safety. The objective of this study is to determine the effect of a transitional pharmaceutical care program on unplanned rehospitalisations. Methods An interrupted-time-series study was performed, including patients from the Internal Medicine department using at least one prescription drug. The program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within six months post-discharge. Secondary outcomes were drug-related hospital visits, drug-related problems (DRPs), adherence, believes about medication, and patient satisfaction. Interrupted time series analysis was used for the primary outcome and descriptive statistics were performed for the secondary outcomes. Results In total 706 patients were included. At 6 months, the change in trend for unplanned rehospitalisations between usual care and the program group was non-significant (− 0.2, 95% CI -4.9;4.6). There was no significant difference for drug-related visits although visits due to medication reconciliation problems occurred less often (4 usual care versus 1 intervention). Interventions to prevent DRPs were present for all patients in the intervention group (mean: 10 interventions/patient). No effect was seen on adherence and beliefs about medication. Patients were significantly more satisfied with discharge counselling (68.9% usual care vs 87.1% program). Conclusions The transitional pharmaceutical care program showed no effect on unplanned rehospitalisations. This lack of effect is probably because the reason for rehospitalisations are multifactorial while the transitional care program focused on medication. There were less hospital visits due to medication reconciliation problems, but further large scale studies are needed due to the small number of drug-related visits. (Dutch trial register: NTR1519).

Download Full-text

EMERGING MODELS OF CARE: THE IMPACT OF PHARMACIST-LED MEDICATION MANAGEMENT IN A TRANSITIONAL CARE PROGRAM

Innovation in Aging ◽

10.1093/geroni/igz038.2602 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S708-S708

Author(s):

Ebony Andrews ◽

Travonia Brown-Hughes ◽

Ronald Lyon ◽

Shanea D Parker ◽

Brad Lazernick

Keyword(s):

Transitional Care ◽

Medication Management ◽

Hospital Readmissions ◽

Care Transitions ◽

Patient Activation ◽

Care Program ◽

Transition Process ◽

Models Of Care ◽

Care Transition ◽

The Impact

Abstract Transitional care programs have emerged as successful models of care in which to reduce cost and improve health outcomes. However, few transitional care models have directly incorporated the expertise of the pharmacist as an integral member of the care coordination team. Therein lies an inherent limitation of many community-based transitional care programs, the underutilization of pharmacist during all stages of the care transition process. In 2013, the Hampton Roads Care Transitions Project (HRCTP), a partnership between Senior Services of Southeastern Virginia Area Agency on Aging in Norfolk, VA and Hampton University School of Pharmacy, was established. The goal of the HRCTP is to provide medication management services to reduce preventable hospital readmissions for adults 60 years of age and older with targeted diagnoses. Pharmacists work in collaboration with social workers who act as HRCTP care transition coaches. Between May 2017- October 2018, 678 patients were enrolled in the HRCTP. The hospital readmission rate among patients with targeted diagnoses was reduced by 55.3% with an absolute percentage point reduction of 9.9% and estimated savings amount per avoided readmission of $14,400. Patients who participated in the HRCTP showed a 14% increase in the Patient Activation Assessment indicating an improvement in self-managing efficacy. 93% of patients/caregivers indicated they felt more confident in their ability to manage their health, and 91% expressed satisfaction with the program. The program has proven effective in assisting seniors to remain in their home, reducing hospitalizations, promoting health, increasing patient satisfaction, and reducing healthcare cost.

Download Full-text

A pragmatic randomized controlled trial of a cardiac hospital-to-home transitional care program in a Singapore academic medical center

Journal of Patient Safety and Risk Management ◽

10.1177/2516043520914196 ◽

2020 ◽

Vol 25 (2) ◽

pp. 55-66

Author(s):

Yanying Chen ◽

Yi Jin Tan ◽

Ya Sun ◽

Cheng Zhan Chua ◽

Jeffrey Kwang Sui Yoo ◽

...

Keyword(s):

Quality Of Life ◽

Emergency Department ◽

Transitional Care ◽

Controlled Trial ◽

Care Program ◽

Emergency Department Visits ◽

Pragmatic Randomized Controlled Trial ◽

Randomized Controlled ◽

Hospital To Home

Background Rehospitalizations are common in healthcare. They are costly for hospitals and patients and a substantial percentage are preventable, partly because hospital-to-community transitions are often unmanaged or poorly managed. In this study, we conducted a pragmatic randomized, controlled trial to evaluate the effectiveness of a new nurse–practitioner-led transitional care program called CareHub, piloted in Singapore’s National University Hospital. Methods Study population included all eligible cardiac patients admitted between July 2016 and November 2016. Patients were followed for six months post-discharge. Primary outcomes other than emergency department visits were all cardiac-related: number of readmissions, specialist visits, emergency department visits, and total days readmitted. Secondary outcomes: variables related to quality of life and transitional care. Regression analyses were used to estimate the intent-to-treat effect of CareHub and explore treatment heterogeneity. Results CareHub reduced the mean number of unplanned readmissions by 0.23 (a 39% reduction relative to control mean of 0.60 unplanned readmissions, p < 0.05), mean number of all readmissions by 0.20 (31% reduction relative to control mean of 0.63 readmissions, p = 0.10), mean number of total unplanned days in hospital by 2.2 (56% reduction relative to control mean of 4.0 days, p < 0.05), mean number of total days in hospital by 2.0 (42% reduction relative to control mean of 4.3 days, p < 0.10). Treatment effects varied by pre-admission health and socio-economic status. Conclusion A carefully designed protocolized cardiac hospital-to-home transition program can reduce resource utilization while improving quality of life.

Download Full-text