Outcomes of a Post-Discharge Physician Home Visit Intervention to Reduce Hospital Readmissions for High-Risk Patients

Background:

Healthcare organizations are currently devoting significant resources to efforts to reduce hospital readmission after discharge.  Multiple factors have been linked to readmission, including an absence of outpatient follow-up care, inadequate understanding of discharge instructions and medication errors.  Post-hospitalization home visits by physicians and mid-level providers are a potential mechanism for addressing these factors and helping reduce readmission.

Methods:

In 2013, WakeMed Health and Hospitals in Raleigh, NC, partnered with Paired Health (now C³HealthCareRx) to provide post-hospitalization home visits with the goal of improving the transition from hospital to home.  Referrals were made by inpatient attendings and case managers for individuals felt at high-risk for readmission.  Referrals were encouraged for patients with repeat hospitalizations and emergency room visits, patients without primary care physicians and patients who had missed post-discharge follow-up after prior admissions.  Participants were risk-stratified utilizing a tool modeled on the Project BOOST “8P scale” to determine the intensity of service.  Patients were followed for up to 30-days, or until care was assumed by a primary care physician, whichever occurred first.  Retrospectively we reviewed 30-day readmission data for the participants of the program during the first two years of implementation.  This was compared to the hospital’s Medicare readmission rate as well as overall hospital readmission rate during that same two year period.

Results:

A total of 904 patients participated in the intervention during that two year period, receiving on average of 2.6 home visits following hospitalization.  During the 30-day period following discharge, 59 participants (6.5%; 95% CI 4.9-8.1%) were readmitted to WakeMed.  In comparison during that period, 2697 Medicare patients (12.0%; 95% CI 11.6-12.4%) were readmitted (p-value <0.002) and 4343 total patients (8.3%; 95% CI 8.1-8.5%) were readmitted (p-value 0.056).

Conclusions:

This home visit intervention for high-risk patients demonstrated an improved readmission rate compared to the hospital’s Medicare readmission rate.  It demonstrated at least equal readmission rates compared to the overall hospital readmission rate.  This study does have some limitations including its observational nature, differences between our intervention and comparison groups and an inability to measure readmissions to other hospitals.  However, it does suggest physician and mid-level provider post-hospitalization home visits can be a part of a healthcare organization’s strategy to reduce readmissions.