Background: The Hospital Readmission Reduction Program (HRRP), established under the Affordable Care Act (ACA), caused health care systems to reevaluate the discharge process to avoid payment reduction for excess readmissions. The post-hospitalization follow-up appointment is a key factor in preventing readmissions. While the HRRP provides recommendations on time to follow-up for select diagnoses, those known to be of higher risk for readmission, there are no other standards of care provided. Taking this into consideration, supplemented by the underserved and complex population of a graduate medical education environment, our multidisciplinary disposition clinic was designed with an aim to reduce the 30-day readmission.
Methods: Chart review was conducted for baseline data analysis from March 2019 through the disposition clinic opening on August 14th, 2019. Patients were included if they met one of the following criteria: admitted under the housestaff service or were an established outpatient admitted to another primary service with housestaff consultation and followed up after discharge.The primary endpoint was the 30-day readmission rate followed by three secondary endpoints: 30-day observation or emergency department visits, readmission up to 90-days, and average days to follow-up. The first PDSA cycle compared our standard discharge follow-up with the multidisciplinary clinic. The standard process consisted of patients being seen in the housestaff continuity clinic in a 15-minute time slot. The multidisciplinary clinic created extended time slots, one afternoon per week, consisting of a hospitalist, designated resident, pharmacist and rounding transition of care (TOC) nurse. Additional clinic staff were dependent on patient requests and included financial aid and social work. Unexpectedly, PDSA cycle two started on January 11th, 2020 following the vacancy of the TOC nursing position. Cycle two ended on March 11th, 2020 as a result of the global pandemic and shift to telehealth medicine.
Results: Including baseline data, a total of 247 unique patients were reviewed creating 326 separate encounters over the study period. The standard clinic evaluated one-hundred and seventy-five patients in 244 separate encounters; average age of 59.7 years with 65% females.. The multidisciplinary clinic evaluated seventy-two patients in 82 separate encounters: average age 54.9 years with 50% females. Baseline analysis (n= 152) of the primary endpoint, 30-day readmission, was 18.42%, 95 CI [13.1, 25.3]. PDSA cycle one demonstrated comparable readmissions between the control group (n= 60) 15 %, 95 CI [8.1, 26.1] and intervention group (n= 57) at 14%, 95 CI [7.3, 25.3]. PDSA cycle two demonstrated a higher readmission rate in the intervention group (n= 25) at 28%, 95 CI [14.3, 47.6] compared with the standard (n= 32) at 12.5%, 95 CI [5, 28.1] however was not statistically significant. In addition, there were no statistically significant secondary endpoints reviewed.
Conclusions: Despite not demonstrating statistically significant data, our study provided insight into the key components of preventing 30-day readmission, communication and coordination of care. Understanding the limitations of our study; the unexpected key staff vacancy and early termination of cycle two will create an opportunity to readdress our aim and interventions once normalcy has resumed.