High Risk Of Hospital Readmission Research Articles

The number of discharge medications predicts thirty-day hospital readmission: a cohort study.

BackgroundHospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined.MethodsTo determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications.ResultsThe final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17–1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643–0.679]).ConclusionsThe number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.

Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population

BackgroundCare transition programs can potentially reduce 30 day readmission; however, the effect on long-term hospital readmissions is still unclear. ObjectiveWe compared short-term (30 day) and long-term (180 day) utilization of participants enrolled in care transitions versus those matched referents eligible but not enrolled. DesignThis cohort study was conducted from January 1, 2011 until June 30, 2013 within a primary care academic practice. ParticipantsPatients at high risk for hospital readmission based on age and comorbid health conditions had participated in care transitions group (cases) or usual care (referent). Main measuresThe primary outcomes were 30, 90, and 180 day hospital readmissions.. Secondary outcomes included: mortality; emergency room visits and days; combined rehospitalizations and emergency room visits; and total intensive care unit days. Cox proportional hazard models using propensity score matching were used to assess rehospitalization, emergency room visits and mortality. Poisson regression models were used to compare the numbers of hospital days. Key resultsCompared to referent (n=365), Mayo Clinic Care Transitions patients exhibited a lower 30 day rehospitalization rate compared to referent; 12.4% (95% CI 8.9–15.7) versus 20.1% (95% CI 15.8–24.1%), respectively (P=0.002). At 180-days, there was no difference in rehospitalization between transitions and referent; 39.9% (95% CI 34.6–44.9%) versus 44.8% (95% CI 39.4–49.8%), (P=0.07). ConclusionWe observed a reduction in 30 day rehospitalization rates among those enrolled in care transitions compared to referent. However, this effect was not sustained at 180 days. More work is needed to identify how the intervention can be sustained beyond 30 days.

Implementing a Transitional Care Program for Older Adults at High Risk for Readmission

Background/Aims: This study describes the implementation of a transitional care program for older adults at high risk for hospital readmission. Despite increasing efforts to reduce preventable readmissions through postdischarge care coordination, little research has been done on how to operationalize transitional care in community settings. We sought to understand how implementation efforts were impacted by factors including intervention complexity, patient beliefs about transitional care, and program fidelity with ramifications on staff roles and scope of work.

Functional Status and Hospital Readmissions Using the Medical Expenditure Panel Survey.

Hospital readmissions are expensive and they may signal poor quality of care. Whether functional status is related to hospital readmissions using a representative U.S sample remains unexplored . We aimed to assess the relationship between functional status and all-cause 30-day hospital readmissions using a representative sample of the US population. This was a retrospective observational study (2003-2011). The study included 3,772 patients who completed the SF-12 before being hospitalized. Three hundred and eighteen (8.4%) were readmitted within 30 days after being discharged. The Medical Expenditure Panel Survey (MEPS) was employed. Functional status was measured with the Short-Form 12-Item Health Survey Version 2® (SF-12). The probability of being readmitted was estimated using a logistic model controlling for demographic characteristics, comorbid conditions, insurance coverage, physical (PCS) and mental (MCS) summaries of the SF-12, reason for hospitalization, length of hospital stay, region, and residential area. A one-unit difference in PCS reduced the odds of readmission by 2% (odds ratio 0.98 [95% CI, 0.97 to 0.99]; p < 0.001), which implies an 18% reduction in the odds of readmissions for a ten-unit difference (one standard deviation) in PCS. The c-statistic of the model was 0.72. Baseline physical function is associated with hospital readmissions. The SF-12 improves the ability to identify patients at high risk of hospital readmission.

Abstract W MP61: Relationship Between Tracheostomy and Readmission Rates Among Mechanically Ventilated Patients with Stroke

Introduction: Patients with ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) who undergo mechanical ventilation (MV) frequently require tracheostomy for management of persistent respiratory failure. Given the potential complications of chronic immobility and respiratory failure, these patients may be at high risk for hospital readmission. Methods: Using previously validated ICD-9-CM codes and statewide administrative claims data from California (2005-2011), Florida (2005-2012), and New York (2006-2011), we compared readmission rates among patients with a first-recorded stroke (IS, ICH, or SAH) who received MV and were discharged with or without a tracheostomy. Survival statistics and Poisson regression analyses with robust standard errors were used to report rates of hospital readmission and the association between tracheostomy and readmission rates. Results: Among 39,881 patients with stroke who underwent MV, 10,690 received a tracheostomy. The rate of any readmission was 21.1% (95% CI 20.3-21.9%) at 1 month and 45.1% (95% CI 44.2-46.1%) at 1 year among patients with tracheostomy versus 17.1% (95% CI 16.6-17.5%) and 35.3% (95% CI 34.8-35.9%) among those without a tracheostomy. The overall readmission rate throughout follow-up was 5.03 (95% CI 5.00-5.07) readmissions per 100 patients per month in those with tracheostomy versus 3.69 (95% CI 3.64-3.73) in those without tracheostomy. After adjustment for stroke type, demographic characteristics, vascular risk factors, Elixhauser comorbidities, stroke complications (e.g., seizures), and discharge disposition from the index hospitalization, tracheostomy was associated with a slightly increased readmission rate (incidence rate ratio, 1.04; 95% CI 1.00-1.08, p=0.04). Conclusion: Readmission rates among mechanically ventilated patients with stroke were not substantially higher than overall readmission rates seen in the general hospitalized population of elderly patients. There was a statistically significant but not clinically meaningful association between tracheostomy placement and readmission rates. These data may be helpful when counseling the families of patients with severe stroke.

Characterizing Readmission in Ulcerative Colitis Patients Undergoing Restorative Proctocolectomy

BackgroundPostoperative readmissions increase costs and affect patient quality of life. Ulcerative colitis (UC) patients are at a high risk for hospital readmission following restorative proctocolectomy (RP). ObjectiveThe objective of this study is to characterize UC patients undergoing RP and identify causes and risk factors for readmission. DesignA retrospective review of a prospectively maintained institutional database was performed. Postoperative readmission rates and reasons for readmission were examined following RP. Univariate and multivariate analyses were performed to evaluate for risk factors associated with readmission. ResultsOf 533 patients who met our inclusion criteria, 18.2 % (n = 97) were readmitted within 30 days while 22.7 % (n = 121) were readmitted within 90 days of stage I of RP. Younger patient age (OR 1.825, 95 % CI 1.139–2.957), laparoscopic approach (OR 1.943, 95 % CI 1.217–3.104), and increased length of initial stay (OR 1.155, 95 % CI 1.090–1.225) were all associated with 30-day readmission. The most common reason for readmission was dehydration/ileus/partial bowel obstruction, with 10 % of patients readmitted for this reason within 30 days. ConclusionsPatients undergoing restorative proctocolectomy are at high risk for readmission, particularly following the first stage of the operation. Novel treatment pathways to prevent ileus and dehydration as an outpatient may decrease the rates of readmission following RP.

Risk Factors for Readmission after Allogeneic Hematopoietic Stem Cell Transplantation and Impact on Overall Survival

Patients treated with allogeneic hematopoietic stem cell transplantation (HSCT) are presumed to be at high risk for hospital readmission. The objective of this study was to identify the incidence and associated risk factors for readmissions in allogeneic HSCT patients and to evaluate the effect of readmissions on overall survival. In this retrospective review, we included 1141 HSCT patients (503 patients receiving a myeloablative [MAC] HSCT and 638 a reduced-intensity conditioning [RIC] HSCT). We measured rates of readmission at 30 days after discharge from HSCT and by day +100 after HSCT. Reasons for readmission, risk factors for readmission, and effect on overall survival were assessed. In the MAC group, 130 of 459 (28.3%) patients were readmitted within 30 days of discharge and 195 of 456 (42.8%) patients by day 100. In the RIC group, 105 of 600 (17.5%) patients were readmitted within 30 days of discharge and 185 of 595 (31.1%) patients by day 100. There were significantly more readmissions in the MAC group at both the 30-day (P < .001) and day +100 time points (P < .001). The most frequent reason for readmission was infection (28.2% in MAC group, 27.3% in RIC group). The occurrence of infection during the index admission was the only risk factor significant in both groups at both time points in the multivariable regression analysis. Readmission was significantly associated with decreased overall survival in both groups and at both time points. MAC patients are readmitted significantly more than RIC patients. Infection is the most common cause of readmission after HSCT and the occurrence of infection during the index transplantation admission is a significant risk factor for readmission. Readmission within 30 days of discharge and by day +100 after transplantation was a significant risk factor for a lower 5-year overall survival rate in both groups.

Patients undergoing total laryngectomy: an at-risk population for 30-day unplanned readmission.

Patients undergoing total laryngectomy are at high risk for hospital readmission. Hospital readmissions are increasingly scrutinized because they are used as a metric of quality care and are subject to financial penalties. To determine the rate of, reasons for, and risk factors that predict 30-day unplanned readmission for patients undergoing total laryngectomy. Retrospective cohort study at a single academic tertiary referral medical center. The study population comprised 155 patients who underwent total laryngectomy with or without flap closure between January 2007 and December 2012 as either a primary treatment or salvage treatment for prior nonsurgical management. Total laryngectomy. Rate of 30-day unplanned readmission, readmission diagnoses, and risk factors for unplanned readmission. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission within 30 days of discharge. The 30-day unplanned readmission rate for patients following discharge after total laryngectomy was 26.5% (41 of 155). The most common readmission diagnoses were pharyngocutaneous fistula (27% of readmissions; n = 11) and stomal cellulitis (16% of readmissions; n = 7). The median time to unplanned readmission was 7 days. Thirty-four percent of readmissions (14 of 41) occurred within 3 days of discharge. Significant predictors of 30-day unplanned readmission on multivariable analysis were postoperative complication after discharge (odds ratio [OR], 11.50; 95% CI, 4.10-32.28), visit to the emergency department within 30 days after discharge (OR, 5.25; 95% CI, 1.84-14.99), salvage total laryngectomy (OR, 3.52; 95% CI, 1.56-13.12), and chyle fistula during the index hospitalization (OR, 5.25; 95% CI, 0.86-29.92). The discriminative ability of the model to predict unplanned readmission, as measured by the C statistic, was 0.88. Patients undergoing total laryngectomy are an at-risk patient population with a high rate of unplanned readmission within 30 days of discharge. By identifying the risk factors that predict 30-day unplanned readmission, these data can be used to design and implement quality-improvement interventions to decrease readmissions.

Physician visits and 30-day hospital readmissions in patients receiving hemodialysis.

A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasi-experimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and $240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.

Validation of a Predictive Model to Identify Patients at High Risk for Hospital Readmission.

Hospital readmission is an adverse patient outcome that is serious, common, and costly. For hospitals, identifying patients at risk for hospital readmission is a priority to reduce costs and improve care. The purposes were to validate a predictive algorithm to identify patients at a high risk for preventable hospital readmission within 30 days after discharge and determine if additional risk factors enhance readmission predictability. A retrospective study was conducted on a randomized sample of 598 patients discharged from a Southeast community hospital. Data were collected from the organization's database and manually abstracted from the electronic medical record using a structured tool. Two separate logistic regression models were fit for the probability of readmission within 30 days after discharge. The first model used the LACE index as the predictor variable, and the second model used the LACE index with additional risk factors. The two models were compared to determine if additional risk factors increased the model's predictive ability. The results indicate both models have reasonable prognostic capability. The LACE index with additional risk factors did little to improve prognostication, while adding to the model's complexity. Findings support the use of the LACE index as a practical tool to identify patients at risk for readmission.

Aplicación de The Community Assessment Risk Screen en centros de atención primaria del Sistema Sanitario Valenciano

ObjectiveApplication of The Community Assessment Risk Screen (CARS) tool for detection of chronic elderly patients at risk of hospital readmission and the viability study for its inclusion in health information systems. DesignRetrospective cohort study. LocationHealth Departments 6, 10, and 11 from the Valencia Community. ParticipantsPatients of 65 and over seen in 6 Primary Care centres in December 2008. The sample consisted of 500 patients (sampling error=±4.37%, sampling fraction=1/307). VariablesThe CARS tools includes 3items: Diagnostics (heart diseases, diabetes, myocardial infarction, stroke, COPD, cancer), number of prescribed drugs and hospital admissions or emergency room visits in the previous 6months. The data came from SIA-Abucasis, GAIA and MDS, and were compared by Primary Care professionals. The end-point was hospital admission in 2009. ResultsCARS risk levels are related to future readmission (P<.001). The value of sensitivity and specificity is 0.64; the tool accurately identifies patients with low probability of being hospitalized in the future (negative predictive value=0.91, diagnostic efficacy=0.67), but has a positive predictive value of 0.24. ConclusionsCARS does not properly identify the population at high risk of hospital readmission. However, if it could be revised and the positive predictive value improved, it could be incorporated into the Primary Care computer systems and be useful in the initial screening and grouping of chronic patients at risk of hospital readmission.

S88 1 Year UK Survival Readmission Rate in Chronic Obstructive Pulmonary Disease (COPD) Survivors Following Acute Non-Invasive Ventilation (NIV)

Background Previous data has shown that premorbid MRC-dyspnoea (MRCD) score predicts outcomes following acute exacerbation of COPD (Steer, Thorax 2012). There are limited data on the clinical utility of the MRCD in predicting outcomes in patients requiring NIV to treat hypercapnic respiratory failure complicating an acute exacerbation. Methods A single centre observational cohort study was undertaken from 1 st April 2009 to 31 st March 2012. We prospectively followed a cohort of patients admitted with acute exacerbation requiring NIV according to standard BTS criteria. Pre-admission MRCD were calculated from a prospective database obtained from the electronic patient record system as were hospital readmissions and mortality data. Results 119 patients (69 male) with a mean age of 71 ± 12 years were admitted requiring NIV. Mean pH was 7.26 ± 0.07 with a PaCO 2 9.47 ± 2.26 kPa and HCO 3 - of 30.6 ± 6.3 mmols/l. 102 patients (86%) survived the index hospital admission. 16 (16%) patients had previous admissions requiring acute NIV prior to April 2009. 63 (62%) survivors were readmitted or died within 1 year with 26 (25%) survivors having >1 readmission episode and 33 (32%) patients required NIV on readmission within a year. Median 1 year re-admission rate per patient was 1 (1–9) with median time to readmission 228 days for all patients and 373 days, 216 days, 105 days for MRC-dyspnoea score 2–3, 4 and 5, respectively. Median length of stay of the index admission was 9 days (1–48) with median length of readmission, or readmissions of 13 days (1–111). Hospital readmission accounted for 1251 bed days. There was significantly poorer 1 year survival in the most severely dyspnoeic patients (MRC 5) compared to the least (MRC 2 and 3) (HR 0.40, 95% CI 0.18–0.88, p = 0.023). Conclusion These data show that COPD patients who receive acute NIV have high risk of hospital readmission including requirement for repeat NIV treatment, which contributed to a significant number of hospital bed days. Although overall outcomes are better than previously reported (Murray, Thorax 2011), patients with high levels of premorbid dyspnoea have the highest mortality following acute hypercapnic exacerbations of COPD requiring NIV.

Can the targeted use of a discharge pharmacist significantly decrease 30-day readmissions?

The prevalence and cost of hospital readmissions have gained attention. The ability to identify patients at high risk for hospital readmission has implications for quality and costs of care. Medication errors have been shown to increase the risk for readmission. To study the impact of a pharmacist-based predischarge medication reconciliation and counseling program on 30-day readmission rates and determine whether polypharmacy and problem medications are important screening criteria. A prospective, nonrandomized cohort study performed at a single medical-surgical unit with telemetry capability at a single academic medical center. The participants were 729 patients, aged 18 years and older, who were discharged between July 1 and October 29, 2010. The intervention was pharmacist medication reconciliation and counseling based on a screening tool. The primary outcome was 30-day readmission rate. Secondary outcomes were the presence of polypharmacy and problem medications and their relationship with observed 30-day readmission rate, including calculation of a problem med/polypharmacy score. The pharmacy review group (n = 537) had a lower 30-day readmission rate than the group receiving usual care (n = 192) (16.8% vs 26.0%; odds ratio [OR] 0.572; 95% CI, 0.387-0.852; P = .006). Polypharmacy, defined as either 5 or more or 10 or more scheduled medications, alone and in combination with at least one problem medication had higher 30-day readmission rates. A score of no factors present exhibited good negative predictive value. Medication reconciliation and counseling by a pharmacist reduced the 30-day readmission rate. Polypharmacy and problem medications appear to have value individually and together. A pharmacist, guided by a screening tool in predischarge medication reconciliation, is one option to effectively reduce 30-day readmissions.

Building Teams and Bridges to Healthy Transitions (P24)

1.Apply principles of palliative care to transitional care and care coordination initiatives.2.Analyze barriers to and facilitators of effectivecare transitions programs in selected settings.3.Propose strategies to measure the effectiveness of palliative care-based transitions programs. By far, hospital care accounts for the greatest cost to the Medicare program. Reducing hospital readmission has become a target of payment reform as well as quality improvement. Numerous care coordination initiatives have been tested with cohorts of complexly ill older adults at high risk for hospital readmission. To date, there is no single approach that has been shown to be effective across all care delivery settings and populations. Most models have focused on coordinating transitions from hospital to home; there is considerably less evidence regarding transitions across other settings, such as skilled nursing to home. Moreover, there is growing evidence that supports an overemphasis on professionals’ roles and responsibilities paired with under appreciation of the lived experience of chronically ill older adults in communities. Increasingly, palliative care is being viewed as a viable approach to supporting safe transitions—across populations, locations, and goals for care. Using case studies from projects in progress, this session will demonstrate how palliative care can be used to structure effective care transitions approaches, engage formal and informal networks in the community, and tailor and evaluate interventions. Faculty will suggest avenues for future research, program development and policy. HPNA sponsored

Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission

To investigate malnutrition prevalence on presentation to a Medical Assessment and Planning Unit (MAPU) in a setting designed to prevent hospital admission, the association of nutritional status with hospital readmission at 90 days, and agreement of nutritional risk between the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA). Prospective longitudinal cohort study of consecutive patients admitted to MAPU during the first 6 weeks of operation. The main outcome measures were prevalence of malnutrition and hospital readmission at 90 days. Sensitivity and specificity of the MST was assessed against the criterion standard of SGA. The mean participant age was 62 years (n = 153, s.d. 17.4 years) with 50% male (77/153, 95% CI 42-58%). According to the SGA, 17% (95% CI 8-26%) were assessed as malnourished on admission. The MST identified that 18% (95% CI 12-24%) were at nutritional risk, and participants screening positive for nutritional risk had significantly increased odds of hospital readmission at 90 days (OR 3.4, 95% CI, 1.3-9.1, P < 0.029). The MST was practical and successfully identified patients assessed as malnourished within the MAPU setting (sensitivity 73%, specificity 76%, negative predictive value 93%, positive predictive value 38%). Malnutrition is a significant problem in a MAPU setting, and patients screened at nutritional risk are at significantly higher risk of hospital readmission within 90 days.

Developing strategies for predicting and preventing readmissions in vascular surgery

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.

Validity of the Malnutrition Screening Tool for Older Adults at High Risk of Hospital Readmission

Malnutrition is a serious problem in older adults, particularly for those at risk of hospital readmission. The essential step in managing malnutrition is early identification using a valid nutrition screening tool. The purpose of this study was to validate the Malnutrition Screening Tool (MST) in older adults at high risk of hospital readmission. Two RNs administered the MST to identify malnutrition risk and compared it with the comprehensive Subjective Global Assessment (SGA) to assess nutritional status for patients 65 and older who had at least one risk factor for hospital readmission. The MST demonstrates substantial sensitivity, specificity, and agreement with the SGA. These findings indicate that nursing staff can use the MST as a valid tool for routine screening and rescreening to identify patients at risk of malnutrition. Use of the MST may prevent hospital-acquired malnutrition in acute hospitalized older adults at high risk of readmission.

Impacting Readmission Rates and Patient Satisfaction: Results of a Discharge Pharmacist Pilot Program

Background Readmission to a hospital within 30 days of discharge has become a key quality outcome measure. With an observed 30-day readmission rate as high as 20% and attributed costs of almost $17.4 billion a year for Medicare patients, the potential implications for patients and the entire health care system are significant. Medication-related complications have been shown to increase the risk for unplanned readmission. Pharmacists have an opportunity to impact quality and cost by risk stratifying and identify patients at high risk for hospital readmission. Objective To study the impact of a pharmacist-driven discharge counseling program for high-risk patients identified by BOOST (Better Outcomes for Older adults through Safe Transitions) criteria on 30-day readmission rates. Method This was a prospective, cohort, nonrandomized trial at a single medical-surgical unit with telemetry capability at a single academic medical center including 669 patients who were older than 18 years. Primary outcome was 30-day readmission rate. Secondary outcomes were the number and type of pharmacist interventions, cost avoidance, and patient satisfaction results. Results The readmission rate for patients counseled by a pharmacist during the discharge process was 15.7% compared to 21.6% for patients not counseled by a pharmacist on discharge (relative risk [RR] 0.728; 95% confidence interval [CI], 0.514–1.032; P = .04). The readmission rate for adult medicine patients not counseled at discharge by a pharmacist in the study was comparable to the readmission rates of a similar patient control group at 3 months and 1 year prior to the initiation of the study (18.7% and 19.1% vs 19.6%). Conclusions Pharmacists' support in the discharge process facilitated increased communication on the multidisciplinary team and resulted in a lower unplanned readmission rate for patients.

An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study

BackgroundA small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.MethodsCommunity and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.ResultsNineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.ConclusionsA pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.Trial registrationClinicaltrials.gov Identifier: NCT01292096

Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial

During hospitalization older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living (ADLs) and walking ability. A randomized controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored programme for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge. The programme was designed to improve health-promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of ADL, Instrumental Activities of Daily Living (IADL) and the Walking Impairment Questionnaire (WIQ; modified). Significant improvements were found in the intervention group in IADL scores (P < 0.001), ADL scores (P < 0.001) and WIQ scale scores (P < 0.001) in comparison to the control group. The greatest improvements were found in the first 4 weeks following discharge. Early introduction of a transitional model of care incorporating a tailored exercise programme and regular telephone follow-up for hospitalized at-risk older adults can improve independence and functional ability.