An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population

BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

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Implementation of a pharmacist-led transitional care clinic

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa080 ◽

2020 ◽

Vol 77 (12) ◽

pp. 966-971

Author(s):

Sara N Layman ◽

Whitney V Elliott ◽

Sloan M Regen ◽

Leigh Anne Keough

Keyword(s):

High Risk ◽

Care Provider ◽

Transitional Care ◽

Chronic Obstructive ◽

Readmission Rates ◽

Care Clinic ◽

High Risk Patients ◽

State Management ◽

Risk Patients

Abstract Purpose To describe a pharmacist-led transitional care clinic (TCC) for high-risk patients who were recently hospitalized or seen in the emergency department (ED). Summary The Memphis Veterans Affairs Medical Center (VAMC) established a pharmacist-led face-to-face and telephone follow-up TCC to improve posthospitalization follow-up care through medication optimization and disease state management, particularly for veterans with high-risk disease states such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). The clinic’s clinical pharmacy specialists (CPSs) ordered diagnostic and laboratory tests, performed physical assessments, and consulted other providers and specialty services in addition to performing medication reconciliation, compliance assessment, and evaluation of adverse drug events. TCC patients were typically seen within 2 weeks of discharge and subsequently referred back to their primary care provider or a specialty care provider for continued management. A retrospective review of 2016 TCC data found that 7.8% of patients seen in the TCC were readmitted within 30 days of discharge; readmission rates for COPD and HF were reduced to 13% and 10%, respectively, compared to hospital-wide readmission rates of 17% and 24%. A separate observational analysis found that 30-day readmissions for COPD and HF were reduced in TCC patients, with pharmacists documenting an average of 6.2 interventions and 3.3 medication-related problems per patient. To reduce clinic appointment no-shows, the CPSs worked with inpatient providers and schedulers to emphasize to patients the importance of clinic attendance; also, TCC services were expanded to include telehealth appointments to increase access for rural and/or homebound patients. Conclusion A pharmacist-led TCC effectively reduced readmissions and prevented medication-related problems for high-risk patients who were hospitalized or seen in the ED.

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Impact of Heart Failure Focused Follow-Up Care at the “Heart Success Clinic” on 30-Day Readmission Rates in Patients with Congestive Heart Failure

Journal of Cardiology Research Review & Reports ◽

10.47363/jcrrr/2020(1)103 ◽

2020 ◽

pp. 1-3

Author(s):

Deepti Bhandare ◽

Keyword(s):

Heart Failure ◽

Patient Outcomes ◽

Readmission Rate ◽

The United States ◽

Hospital Data ◽

Readmission Rates ◽

Medication Reviews ◽

Improve Patient

Nearly 6.2 million people in the United states are affected by heart failure, it is predicted that this number will rise to 8.5 million by 2030 Significant effort has been made to prevent heart failure and its exacerbations. The Hospital Readmission Reduction Program (HRRP), a Medicaare based program, was established to link payment to quality of care. Payment is reduced to hospitals when patients are readmitted within 30 days for heart failure The “Heart Success Clinic” is an outpatient clinic started to improve patient outcomes and reduce readmission rates. Patients are provided with heart failure focused visits which includes detailed medication reviews, diet modification, weight loss, disease education, etc. During the six months prior to the opening of the clinic, the readmission rate was 15.27% at AdventHealth Sebring hospital which is a community-based hospital. Data was collected on the patients who attended the “Heart Success Clinic” for six months. Zero patients from the clinic were readmitted, bringing the readmission rate down from 15.27% to 0%. This pilot study gives promising initial results. Further studies can be conducted over a longer period time as to gather more patients. Overall, the study demonstrates that there is value in providing heart failure focused follow up visits in improving patient outcomes and readmission rates.

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Impact of pharmacist-conducted anticoagulation patient education and telephone follow-up on transitions of care: a randomized controlled trial

BMC Health Services Research ◽

10.1186/s12913-021-06156-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Lamis R. Karaoui ◽

Elsy Ramia ◽

Hanine Mansour ◽

Nisrine Haddad ◽

Nibal Chamoun

Keyword(s):

Tertiary Care ◽

Intervention Group ◽

Bleeding Event ◽

Transitions Of Care ◽

Control Group ◽

Published Data ◽

Post Discharge ◽

Readmission Rates ◽

The Impact

Abstract Background There is limited published data in Lebanon evaluating the impact of supplemental education for anticoagulants use, especially DOACs, on clinical outcomes such as bleeding. The study aims to assess the impact of pharmacist-conducted anticoagulation education and follow-up on bleeding and readmission rates. Methods This study was a randomized, non-blinded interventional study conducted between August 2017 and July 2019 in a tertiary care teaching Lebanese hospital. Participants were inpatients ≥18 years discharged on an oral anticoagulant for treatment. Block randomization was used. The control group received the standard nursing counseling while the intervention group additionally received pharmacy counseling. Phone call follow-ups were done on day 3 and 30 post-discharge. Primary outcomes included readmission rates and any bleeding event at day 3 and 30 post-discharge. Secondary outcomes included documented elements of education in the medical records and reported mortality upon day 30 post-discharge. Results Two hundred patients were recruited in the study (100 patients in each study arm) with a mean age of 73.9 years. In the pharmacist-counseled group, more patients contacted their physician within 3 days (14% versus 4%; p = 0.010), received explicit elements of education (p < 0.001) and documentation in the chart was better (p < 0.05). In the standard of care group, patients were more aware of their next physician appointment date (52% versus 31%, p < 0.001). No difference in bleeding rates at day 3 and 30 post-discharge was observed between the groups. Conclusions Although pharmacist-conducted anticoagulation education did not appear to reduce bleeding or readmission rates at day 30, pharmacist education significantly increased patient communication with their providers in the early days post-discharge. Trial registration Lebanon Clinical Trial Registry LBCTR2020033424. Retrospectively registered. Date of registration: 06/03/2020.

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Tracking the Rise of Geriatric Emergency Departments in the United States

Journal of Applied Gerontology ◽

10.1177/0733464818813030 ◽

2018 ◽

Vol 39 (8) ◽

pp. 871-879 ◽

Cited By ~ 2

Author(s):

John G. Schumacher ◽

Jon Mark Hirshon ◽

Phillip Magidson ◽

Marilyn Chrisman ◽

Terisita Hogan

Keyword(s):

Emergency Department ◽

Emergency Care ◽

Emergency Departments ◽

The United States ◽

Transitions Of Care ◽

Emergency Department Care ◽

Equipment And Supplies ◽

Care Services ◽

Physical Environments

The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored “geriatric emergency department” model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs’ familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.

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763. 30 Day Readmission Outcomes in Patients Over 80 Years of Age Enrolled in an Outpatient Parenteral Antibiotic Therapy (OPAT) Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.831 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S339-S340

Author(s):

Kathleen R Sheridan ◽

Joshua Wingfield ◽

Lauren McKibben ◽

Natalie Clouse

Keyword(s):

Readmission Rate ◽

Chart Review ◽

Age Groups ◽

Retrospective Chart Review ◽

Model Of Care ◽

Readmission Rates ◽

Parenteral Antibiotic ◽

Patient Demographics

Abstract Background OPAT is a well-established model of care for the monitoring of patients requiring long-term IV antibiotics1. We have previously reported a reduction in the 30-day readmission rate to our facility for patients managed in our OPAT program. However, little has been published to date regarding outcomes in OPAT patients over 80 years of age 2–3. Our OPAT program was established in 2013. Patients can be discharged to a facility or home to complete their course of antibiotics. Methods We conducted a retrospective chart review of all OPAT patients discharged from our facility from 2015 to 2018. Patients were divided into two groups based on age, <80 (n = 4618) and >80 (n = 562). Results Patient demographics are listed in Table 1. The overall 30-day readmission rate for patients older than 80 was 27.8%. For patients over 80 that had a follow-up ID clinic appointment, the 30-day readmission rate decreased to 15.7%. For patients younger than 80, the 30-day readmission rate was 36.0% with a decrease to 16.2% if patients were evaluated in the outpatient clinic. Figure 1. Staphylococcus Aureus was the predominant organism in both age categories. Vancomycin was the most common antibiotic used in both age groups followed by β lactams. Conclusion In general, patients aged over 80 years were more likely to be discharged to a facility to complete their antibiotic course than younger patients. These patients also were more likely to have other comorbidities. The 30-day readmission rate in each age group was relatively similar. OPAT in patients over age 80 can have similar 30-day readmission rates as for patients less than 80 years of age Disclosures All authors: No reported disclosures.

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Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients

Surgery Research and Practice ◽

10.1155/2018/4321986 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10

Author(s):

Ahsan Rao ◽

Alex Bottle ◽

Collin Bicknell ◽

Ara Darzi ◽

Paul Aylin

Keyword(s):

Abdominal Aortic Aneurysm ◽

Readmission Rate ◽

High Impact ◽

Short Term ◽

Readmission Rates ◽

Abdominal Aortic ◽

High Readmission Rate ◽

Trajectory Modelling

Introduction. The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results. Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P<0.001), older age (P<0.001), and higher comorbidity score (P<0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P<0.001), heart failure (P = 0.01), peripheral vascular disease (P<0.001), female sex (P = 0.02), open repair (P<0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71. Conclusion. Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

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Age Based Trends for Unplanned Pediatric Rehospitalizations in the United States

10.1101/2021.11.13.21266306 ◽

2021 ◽

Author(s):

Nupur Amritphale ◽

Amod Amritphale ◽

Deepa Vasireddy ◽

Mansi Batra ◽

Mukul Sehgal ◽

...

Keyword(s):

Hospital Readmission ◽

Readmission Rate ◽

Age Groups ◽

The United States ◽

Unplanned Readmission ◽

Post Discharge ◽

Readmission Rates ◽

Discharge Care ◽

Hospital Readmission Rate ◽

Bowel Diseases

BACKGROUND AND OBJECTIVES: Hospital readmission rate helps to highlight the effectiveness of post- discharge care. There remains a paucity of plausible age based categorization especially for ages below one year for hospital readmission rates. METHODS: Data from 2017 Healthcare cost and utilization project National readmissions database was analyzed for ages 0-18 years. Logistic regression analysis was performed to identify predictors for unplanned early readmissions. RESULTS: We identified 5,529,389 inpatient pediatric encounters which were further divided into age group cohorts. The overall rate of readmissions was identified at 3.2%. Beyond infancy, the readmission rate was found to be 6.7%. Across all age groups, the major predictors of unplanned readmission were cancers, diseases affecting transplant recipients and sickle cell patients. It was determined that reflux, milk protein allergy, hepatitis and inflammatory bowel diseases were significant comorbidities leading to readmission. Anxiety, depression and suicidal ideation depicted higher readmission rates in those older than 13 years. Across ages 1-4 yrs, dehydration, asthma and bronchitis were negative predictors of unplanned readmission. CONCLUSIONS: Thirty-day unplanned readmissions remain a problem leading to billions of tax-payer-dollars lost per annum. Effective strategies for mandatory outpatient follow-up may help the financial aspect of care while also enhancing the quality of care.

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Abstract WMP94: Readmission Within 30 days After Acute Ischemic Stroke, United States 2013

Stroke ◽

10.1161/str.48.suppl_1.wmp94 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Xin Tong ◽

Mary G George ◽

Sallyann M Coleman King ◽

Cathleen Gillespie ◽

Robert Merritt

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Readmission Rate ◽

Hospital Readmissions ◽

The United States ◽

Artery Occlusion ◽

Principal Diagnosis ◽

Readmission Rates ◽

The Cost

Introduction: Hospital readmissions contribute significantly to the cost of medical care and reflect the burden of disease. Limited data have been reported on national hospital readmission after acute ischemic stroke. Methods: Among 2013 adult hospitalizations from the National Inpatient Sample of the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD), we identified acute ischemic stroke (AIS) hospitalizations using principal diagnosis ICD-9-CM codes. We provided national estimates of AIS non-elective readmission rates within 30 days. Results: In 2013, there were a total of 489,813 adult index AIS admissions in the United States. The readmission rate within 30 days for a new AIS as the principal diagnosis was 2.1% of index AIS admissions, and was 10.2% of all readmissions. The readmission rate for all non-elective reasons increased with age, with the lowest readmission rate (8.9%) among ages 18-44, and the highest (11.7%).among ages 85+. The readmission rate was higher among patients with public insurance (11.1%) as compared to private (7.4%) or others (7.9%). Recurrent AIS (20.2%) was the most common reason for readmission, including unspecified cerebral artery occlusion with infarction (ICD9-CM=434.91, 13.0%) and cerebral embolism with infarction (ICD9-CM=434.11, 3.1%). In addition, infections were among the most common causes (Septicemia 5.7%, UTI 2.7%, and pneumonia 2.2%) and TIA (2.4%). Conclusions: The findings have important implications for identifying groups and conditions at high-risk for readmission. The large number of recurrent AIS within 30 days of index AIS highlights the need for improved patient follow-up and secondary prevention treatment.

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1309. Effects of a Pharmacist-Driven Antiretroviral Stewardship and Transitions of Care Service in Persons Living with HIV/AIDS

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1172 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S471-S472

Author(s):

Marisa B Brizzi ◽

Rodrigo M Burgos ◽

Thomas D Chiampas ◽

Sarah M Michienzi ◽

Renata Smith ◽

...

Keyword(s):

Care Service ◽

Transitions Of Care ◽

Hiv Care ◽

Outpatient Clinics ◽

Readmission Rates ◽

Implementation Phase ◽

Persons Living With Hiv ◽

Living With Hiv ◽

Hiv Aids

Abstract Background Historical data demonstrate that PLWHA experience higher rates of medication-related errors when admitted to the inpatient setting. Prior to initiation of this program, rapid-start initiation of antiretroviral therapy (ART) was not implemented prior to discharge. The purpose of this study was to evaluate the impact of a pharmacist-driven antiretroviral stewardship and transitions of care service in persons living with HIV/AIDS (PLWHA). Methods This was a retrospective pre- and post-analysis of PLWHA hospitalized at University of Illinois Hospital (UIH). Patients included were adults following at UIH outpatient clinics for HIV care admitted to UIH for acute care. Data were collected between April 19, 2017 and October 19, 2017 for the pre-implementation phase, and between July 1, 2018 and December 31, 2018 for the post-implementation phase. The post-implementation phase included an HIV-trained clinical pharmacist (Figure 1). Primary and secondary endpoints included follow-up rates at UIH outpatient HIV clinics, 30-day readmission rates, and access to medications at hospital discharge. Statistical analysis included descriptive statistics and Fisher’s Exact test. Results A total of 119 patients were included in the analysis, 66 in the pre-implementation phase and 53 in the post-implementation phase. Patients included were mostly black males with median age of 48. In the pre-implementation phase 50 out of 65 (77%) patients attended follow-up visits for HIV care at UIH outpatient clinics, vs. 42 out of 47 (89%) patients in the post-implementation phase (P = 0.1329). Thirty-day readmission occurred in 17 of 62 (27%) patients in the pre-implementation phase vs. 5 of 52 (10%) of patients in the post-implementation phase (P = 0.0183). During the post-implementation phase, the HIV pharmacist secured access of ART and opportunistic infection medications prior to discharge for 22 patients (42%), 2 of which were new diagnoses. Conclusion A pharmacist-led antiretroviral stewardship and TOC program led to a decrease in 30-day readmission rates in PLWHA. Although not significant, the HIV-pharmacist led to higher rates of clinic follow-up. Finally, the HIV-pharmacist helped secure access to ART and initiate rapid-start therapy in newly diagnosed patients prior to leaving the hospital. Disclosures All authors: No reported disclosures.

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

Neurosurgery ◽

10.1093/neuros/nyz310_434 ◽

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.

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