Background:
Transitions from hospitals to the ambulatory setting are high risk periods for patients. The advent of the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) provide an opportunity for true collaboration in which both inpatient and outpatient providers contribute to improving transitions in care. The goal of this study is to develop, implement, refine, and evaluate a multi-faceted, multi-disciplinary transitions intervention across two hospitals and 18 PCMHs within a Pioneer ACO.
Methods:
We developed an intervention with the following components: inpatient pharmacist-led medication reconciliation and patient counseling; coordination of care and patient education from an inpatient Discharge Advocate and PCMH Responsible Outpatient Clinician; a structured visiting nurse intervention; structured post-discharge phone calls; timely follow-up visits; tools to improve communication among care team members; and optional programs for selected patients, including palliative care consultation and home pharmacist visits. The study utilizes a “stepped wedge” methodology in which each PCMH practice starts in the usual care arm and then at a randomly selected point in time changes to the intervention. Outcomes to date include 30-day post-discharge hospital readmissions using a combination of medical records and patient self-report based on telephone follow-up. Comparisons by study arm are analyzed by Fisher exact test.
Results:
To date, 969 patients have been enrolled (out of a target 1800), including 695 assigned to usual care and 274 assigned to the intervention. Receipt of different components of the intervention varies by component (Table 1) and in some cases by hospital, unit, and practice. Of the 902 patients for whom 30-day outcomes are available, readmission rates are 12.5% in the intervention arm and 14.7% in the usual care arm (p=0.44; Table 2).
Conclusions:
Results to date show a non-significant difference in 30-day readmission rates among patients in the two study arms, due to as of yet insufficient sample size and most likely by lower than expected intervention fidelity. Due to the stepped wedge study design, there is still sufficient time to improve efficacy of the intervention by increasing intervention fidelity, getting feedback on the intervention from patients and providers, and using lessons learned from adjudicated endpoints (preventable post-discharge adverse events and readmissions among intervention patients) to drive iterative refinement of the intervention.
