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Transitional care program lowers readmission rates

Saturday June 29, 2013
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Personal contact with patients before and after their hospital discharge resulted in significantly lower readmission rates, according to a study.

Among 500 patients who received two or more interventions in a special program to manage the transition between hospital and home, 17.6% were readmitted to the hospital within 60 days of discharge. Among a comparison group of 190 patients who received standard care, 26.3% were readmitted, reported researchers with the Bronx Collaborative, a group of hospitals and health insurers in the Bronx, N.Y.

Another 85 patients who received only one intervention for a variety of reasons had a higher readmission rate, raising to 22.8% 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 the patientís 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, according to the research analysis, findings of which were presented June 28 in New Orleans at the annual meeting of the Case Management Society of America and as a poster earlier in the week at the AcademyHealth annual meeting in Baltimore.

The Bronx Collaborative — consisting of three nonprofit hospital systems: Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center; and two payer organizations: EmblemHealth and Healthfirst — developed a uniform care transitions program with the aim of reducing readmissions within 60 days following a discharge from the collaborativeís hospitals.

The 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-transition managers were offered to study participants beginning while hospitalized and continuing for 60 days after discharge, including:

• 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 patientís condition;

• A post-discharge call within 48 to 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 seven to 14 days post-discharge to confirm that the office visit was made and to answer any questions from the patient or caregiver;

• Calls 15 to 60 days post-discharge to check whether there were questions and to follow up on open issues.

"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," Anne Meara, RN, MBA, who led the project design team and is associate vice president of Network Care Management and CMO of Montefiore Care Management, said in a news release.


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