Abstract
BackgroundThe postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. In this study, we aimed to investigate the impact of a quality improvement program, integrated postdischarge transitional care (PDTC), in Taiwan's hospitalist system.MethodsFrom December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan and later discharged alive to home care were included. Efforts to improve the quality of interventions in the PDTC program, including a disease-specific care plan, telephone monitoring, hotline counseling and referral to a hospitalist-run clinic, were implemented in the latter four months in the intervention group, while the control group was recruited during the first two months of the study period. The primary end point was unplanned readmission or death within 30 days after discharge.ResultsThere were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics at the time of admission and at discharge. In the intervention group, 18 patients with worsening disease-specific indicators recorded during telephone monitoring and 21 patients with new or worsening symptoms recorded during hotline counseling had higher rates of unplanned readmission than those without worsening disease-specific indicators (P = 0.031) and worsening symptoms (P = 0.019), respectively. Patients who received PDTC had lower rates of readmission and death than the control group within 30 days after discharge (15% vs. 25%; P = 0.021). Nonuse of a hospitalist-run clinic and presence of underlying malignancy were other independent risk factors for readmission and death within 30 days after discharge.ConclusionIntegrated PDTC using disease-specific care, telephone monitoring, hotline counseling and a hospitalist-run clinic can reduce rates of postdischarge readmission and death.
Highlights
The postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly
Of the 737 patients admitted to the hospitalist ward, only 551 were discharged alive for home care (Figure 1), among whom 139 patients did not match the designated general medical diseases for enrollment, 95 declined enrollment and 4 were defined as not requiring postdischarge transitional care (PDTC)
In this study, we investigated experiences with an integrated PDTC program consisting of a disease-specific care plan, follow-up phone calls, hotline counseling and referral to a hospitalist-run clinic to decrease postdischarge adverse events
Summary
The postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. Short-term postdischarge readmission rates are very high in the elderly, approaching 20% within one month after discharge in a US analysis [5]. The reasons for high readmission rates include poor compliance, instability of chronic disease and insufficient communication between inpatient and outpatient physicians [6]. Close follow-up and communication may prevent adverse events and decrease readmission rates before the primary care physician takes over care continuity [15]
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