Post-Hospital Syndrome (PHS) and Potentially Preventable Hospitalizations(PPH) in Adults. MonashWatch adult cohort patient telehealth journeys (Preprint)

BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘threshold’ identified by HealthLinks Chronic Care (HLCC) algorithms using personal, diagnostic, and service data, excluding surgical and psychiatric admissions. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of health perceptions with more alerts per call indicating greater risk of Potentially Preventable Hospitalizations (PPH) and Post Hospital Syndrome (PHS). Most knowledge of PPH and PHS occurs at a macro-level with little understanding of fine-grained dynamics. OBJECTIVE To describe patterns of self-reported concerns and self-rated health 10 days before and after acute hospital admission in the telehealth intervention cohort of MonashWatch in the context of addressing PPH and PHS. METHODS Participants: 173 who had an acute admission of the of the 232 HLCC cohort with predicted 3+ admissions/year, in MW service arm for >40 days. Measures: Self-reported health and health care status in 764 MW phone call records which were classified into Total Alerts (all concerns - self-reported) and Red Alerts (concerns judged to be higher risk of adverse outcomes/admissions -acute medical and illness symptoms). Acute (non-surgical) admissions from Victorian Admitted Episode database. Analysis: Descriptive Timeseries homogeneity metrics using XLSTAT. RESULTS Self-reported problems (Total Alerts) statistically shifted to a higher level 3 days before an acute admission and stayed at a high level for the 10 days post discharge; reported acute medical and illness symptoms (Red Alerts) increased 1 day prior to admission and but remained at a higher level than before admission. Symptoms of concern did not change before admission or after discharge. Self-rated health and feeling depressed were reported to worsen 5 days post discharge. Patients reported more medication changes up to 2 days before acute admission. CONCLUSIONS These descriptive findings in a cohort of high risk individuals suggest a prehospital phase of what is termed PHS, which persisted on discharge and possibly worsened 5 days after discharge with worse self-rated health and depressive symptoms. Further research is needed. The role and place of community and hospital in such a cohort needs further investigation and research into PPH and PHS.