Spokane Journal of Business

More contact said to result in fewer hospital re-entries

Care transition program involves interactions both before, after discharges

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Personal contact with patients before and after their hospital discharge resulted in significantly lower readmission rates, says a study conducted by the Bronx Collaborative, a group of hospitals and health insurers in Bronx, N.Y.

The results were presented late last month in New Orleans at the annual meeting of the Case Management Society of America, where the study received the society's annual Research Award. The study also was presented at the AcademyHealth annual meeting in Baltimore last month.

Among 500 patients who received two or more personal interventions in a special program to manage the transition between hospital and home, only 18 percent were readmitted to the hospital within 60 days of discharge. That compares with 26 percent among a comparison group of 190 patients who received the current standard of care, the data show.

Another 85 patients who received only one intervention for a variety of reasons had a higher readmission rate, raising to 23 percent the overall 60-day readmission rate for patients in the intervention group.

Interventions included intensive pre-discharge education, the scheduling of a post-discharge follow-up appointment with a patient's personal physician, and post-discharge telephone calls to review medications, identify concerns, and verify the completion of the follow-up physician visit.

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, research analysis suggests.

"These results underscore the value of personal contact with patients before and after their discharge from the hospital and follow-up appointments with their personal physicians to help prevent problems that frequently contribute to readmissions," says Anne Meara, a registered nurse with Bronx-based Montefiore Medical Center who led the collaborative's project design team. "The program was designed to reflect the key concepts of accountable care—improving outcomes and patient satisfaction while lowering costs. We met those goals, and identified opportunities that could possibly be applied successfully at other hospitals."

In addition to Montefiore, the Bronx Collaborative includes two other nonprofit hospital systems, Bronx Lebanon Hospital Center and St. Barnabas Hospital, and two payer organizations, EmblemHealth and Healthfirst, that came together to address health care issues in the Bronx.

The collaborative characterizes the Bronx as 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 with the aim of reducing readmissions within 60 days following a discharge from the collaborative's hospitals.

The program was supported by a grant from the New York State Health Foundation and the New York Community Trust.

The hospital systems contributed in-kind services and the health plans agreed to pay a fee for each patient who received at least two of the interventions in the program's protocol.

The care transitions program 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.

Four interventions by nurse care transitions managers were offered to study participants beginning while hospitalized and continuing for 60 days after discharge.

Those interventions included:

•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 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 between seven days and 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 days and 60 days after 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 and also entered data in a special program developed by the Bronx Regional Health Information Organization.

Additionally, a program pharmacist reviewed medication records and worked with patients who were having problems complying with the prescribed regimen.

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