Background:
Patients who are at risk for readmissions and emergency department visits following hospital discharge frequently have multiple medical comorbidities and a history of multiple prior hospitalizations. Over the past five years, reducing hospital readmissions has increasingly become a priority for hospitals, and effective interventions to reduce readmissions have included multiple components and multiple disciplines. We developed and pilot tested a multidisciplinary transitions of care (TOC) bundle targeted to patients at high risk of readmission. Outcomes of hospital readmissions and emergency department (ED) visits at 30- and 90-days were compared between pilot and control patients.
Methods:
Patients on pilot services were identified upon admission as high risk for readmission using the Parkland readmission risk score embedded into our electronic health record. Enrolled patients received a TOC bundle which included: medication history, medication reconciliation on admission and discharge by pharmacy personnel, medication counseling at discharge by a pharmacist, early assessment of discharge needs by a case manager/social worker team, a post-discharge pharmacist phone call, and primary care follow up within 7 days of discharge. Readmissions and ED visits within 30 and 90 days of discharge were compared to controls. This pilot initiated in August 2014, with the first month designated for rapid process improvement and PDSA cycles. Outcome evaluation began in September, 2014 and continued through July, 2015. The protocol for this study was reviewed and approved by the IRB.
Results:
We enrolled 34 pilot patients and matched 34 control patients by readmission risk score and month of discharge. Pilot patients were on average 51 years old and controls were 54 years old; primary payer was Medicaid for 38% of pilot and 35% of control patients. 30-day readmission rates were 18% for pilot versus 24% for non-pilot patients; 90-day readmission rates were 26% for pilot versus 38% for non-pilot patients. 30-day ED visits not leading to an admission were higher for pilot patients versus non-pilot patients (15% versus 6%) and 90-day ED visits were slightly higher in pilot versus non-pilot patients (24% versus 21%). Composite outcomes of 30- and 90-day readmissions or ED visits were both lower in pilot patients compared to non-pilot patients (30-day composite: 24% vs. 29%; 90-day composite: 35% vs. 47%). Length of stay was somewhat longer in pilot versus control patients (6.8 days pilot versus 6.1 days non-pilot). No differences between groups were statistically significant.
Conclusions:
A multidisciplinary TOC bundle for patients at high risk of readmission shows promise for reducing 30- and 90-day readmissions and for reducing a composite outcome of 30- and 90-day readmissions or ED visits. Although this program was implemented in a small group of patients, results suggest a role for dissemination of program components to reduce hospital readmissions.