Personal contact with patients during care transitions — before and after their hospital discharge — significantly reduced readmission rates, according to a study conducted by the Bronx Collaborative, a group of hospitals and health insurers in the Bronx, N.Y.
Among 500 patients who received two or more of four interventions by nurse care transition managers in a special program to manage the transition between hospital and home, only 17.6 percent were readmitted to the hospital within 60 days of discharge versus 26.3 percent among a comparison group of 190 patients who received the current standard of care, the data showed.
Another 85 patients who received only one intervention for a variety of reasons had a higher readmission rate, raising to 22.8 percent the overall 60-day readmission rate for patients in the intervention group.
The four interventions were offered to study participants beginning while hospitalized and continuing for 60 days after discharge and included the following:
- A pre-discharge educational session with a detailed booklet of discharge instructions, a medication record and a list of symptoms that could indicate a change in the patient’s condition;
- A post-discharge call within 48-72 hours of discharge to identify patient or caregiver concerns, review symptoms and medications and verify that a physician office visit was scheduled for within 14 days of discharge;
- A call at 7-14 days post-discharge to confirm that the office visit was made and to answer any questions from the patient or his or her caregiver;
- Calls between 15-60 days post-discharge to check if there were questions and to follow up on open issues.
A care transitions analyst at each hospital scheduled follow-up physician visits for all patients in the program. A program pharmacist reviewed medication records and worked with patients who were having problems complying with the prescribed regimen.
In addition to receiving at least two interventions, the follow-up physician visit within 14 days of discharge appeared to be a key factor in preventing a readmission, according to the research analysis.
According to the project design team, the program was designed to reflect the key concepts of accountable care — improving outcomes and patient satisfaction while lowering costs.
The Bronx Collaborative includes three non-profit hospital systems — Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center — and two payor organizations, EmblemHealth and Healthfirst, who came together to address healthcare issues in the Bronx, one of the most ethnically diverse and economically deprived counties in the country, with a disproportionate disease burden.
Together they developed a uniform Care Transitions Program (CTP) with the aim of reducing readmissions within 60 days following a discharge from the collaborative’s hospitals. The CTP was made available to Medicare, Medicaid and commercial members of the two health plans. Patients were selected using a predictive model that identified those most at-risk for a readmission based on their diagnoses and the number of readmissions within the preceding 12 months. All participants were Bronx residents age 50 and older and had a working telephone.
Source: Montefiore Medical Center , June 26, 2013
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