Hospital Readmissions Reduction Research Articles

A Targeted Discharge Pathway to Reduce Hospital Readmission and Dying in Hospital in Cancer Patients at the End of Life

ObjectivesThere is a need for better information exchange between primary and secondary care healthcare professionals in cancer patients with limited life expectancy, most of whom prefer to be at home but are admitted frequently at the end of life (EoL). We conducted a file search to assess this among our patients and developed a discharge pathway to decrease readmission rate and dying in hospital. Data SourcesWe performed an in-depth file search among 150 patients who died within 1 month after hospital admission (July 2013 to January 2014); 60 were admitted once, and 90 were admitted twice or more. Mean time spent in hospital at EoL was 12 days; 37% died in hospital, and 49% died at home. We included 31 admitted cancer patients at the EoL in whom home-discharge was planned for the intervention (February 2017 to December 2018). Median survival was 24 days, time spent in hospital decreased from 15.5 to 2.5 days, and number of readmissions fell from 2.8 to 0.57. One patient (3.1%) died in hospital, and 77% died at home. And 78% of general practitioners found the provided information useful. ConclusionA proactive discharge pathway may reduce hospital readmission rates, time spent in hospital, and in-hospital death. Implications for Nursing PracticeEver more patients with complex care needs at the EoL are being discharged early. Being informed about patients’ wishes, preferences, and treatment options for symptom management at home is essential for doctors and nurses in primary care. A systematic discharge pathway can be useful for information transfer when admitted patients are discharged home.

FRI641 Assessing Insulin Prescription Adequacy At Hospital Discharge And Its Association With Characteristics Of Diabetic Patients

Abstract Disclosure: T. Akcan: None. S. Sharma: None. J. Liu: None. A. Jayarangaiah: None. M. Gilani: None. A. Surendran: None. N. Imamudeen: None. R. Gabor: None. R.D. Pathak: None. Diabetes is becoming increasingly prevalent, and appropriate insulin therapy during the post-discharge period is essential to improve glycemic control and reduce readmissions. Despite extensive research on insulin use during hospitalization, little is known about insulin dosing at discharge and patient factors that affect post-discharge needs. Therefore, this retrospective study aimed to evaluate the adequacy of insulin dosing at hospital discharge for diabetic patients and identify patient characteristics impacting post-discharge insulin requirements. Using a retrospective study design, we identified 350 patients meeting the inclusion criteria. The results showed that 19.1% of patients required a decrease in insulin total daily dose (TDD) at follow-up, 50.9% experienced no change, and 30.0% necessitated an increase. Factors found to impact insulin dose adjustments post-discharge include BMI, CKD, discharge TDD, and HbA1c levels. The multivariate analysis revealed that CKD was associated with a decrease in insulin TDD at follow-up (95% CI: -9.65- -0.47, p=0.031). Additionally, insulin TDD at discharge was negatively associated with follow-up dose, with a 0.37 unit decrease (95% CI: -0.44- -0.30, p<0.001) in insulin TDD for each additional unit prescribed. Finally, there was a marginal significance observed in the discharge regimen. Patients on a premixed regimen had a decrease in insulin TDD at follow-up compared to those on a basal-bolus regimen (95% CI: -21.85- 0.27, p=0.057). Our study findings suggest the need for improved estimation of insulin doses at discharge and emphasize the importance of short-term follow-up for insulin titration post-discharge. Patient factors such as body weight, kidney disease, insulin dose at discharge, and HbA1c levels influence these changes. These findings have significant implications for optimizing patient outcomes and reducing hospital readmissions, underscoring the importance of carefully evaluating these factors when tailoring individualized insulin regimens. Presentation: Friday, June 16, 2023

Preventing Heart Failure Readmission in Patients with Low Socioeconomic Position.

This review aims to summarize the current burden of heart failure (HF) in the United States, specifically in patients with low socioeconomic position (SEP), and synthesize recommendations to prevent HF-related hospital readmissions in this vulnerable population. As treatments have improved, HF-related mortality has declined over time, resulting in more patients living with HF. This has led to an increase in hospitalizations, however, putting excess strain on our healthcare system. HF patients with low SEP are a particularly vulnerable group, as they experience higher rates of hospitalization and readmission compared to their high SEP counterparts. The Hospital Readmission Reduction Program (HRRP) was created to motivate interventions that reduce hospital readmissions across diseases, with HF being a primary target. Numerous readmission prevention efforts have been suggested to target the pre-hospitalization, hospitalization, and post-hospitalization phases, including addressing social determinants of health (SDoH), improving coordination of care, optimizing discharge plans, and improving adherence to follow-up care and medication regimens. Many of these proposed interventions show promise in reducing HF-related readmissions and issues surrounding adequate caregiver support may be particularly important to reduce readmissions among persons in low SEP. Reducing HF-related hospital readmissions is possible, even in vulnerable populations like those with low SEP, but this will require coordinated efforts across the healthcare system and throughout the life course of these patients. Caregiver support is a necessary part of optimized care for low SEP HF patients and future efforts should consider interventions that support these caregivers.

Transitions in care: Piloting a neurocritical care clinic with nurse practitioners and physician associates.

The transition period from hospital to home is a vulnerable time for rehospitalization and adverse events for patients. Follow-up clinic visits within 7-14 days of discharge is an effective strategy for reducing hospital readmissions. Neurocritical care patients have a unique set of needs to safely transition to home. We evaluated the feasibility of a Neuroscience Rapid Follow-Up Clinic with nurse practitioners (NPs) and physician associates (PAs) to meet transitional care gaps in neurocritical care patients and prevent rehospitalization. Clinic procedures and documentation templates were customized for the pilot clinic. Five NPs and one PA underwent a brief training course for the ambulatory care setting. Eligible patients were tracked throughout the hospitalization and the team made follow-up appointments. The pilot clinic took place from October 2022 to January 2023. Nine patients were seen in the clinic approximately 8 days after discharge. The clinic attendance rate was 90%. Among the clinic attendees, 66% received referrals to a primary care provider or other services, one third received medication changes or refills and all received patient-specific education. There were no rehospitalizations among the clinic patients. Implementation of this pilot clinic was possible with the current departmental resources. This innovative model of care has the potential to reduce hospital readmissions.

Results of a postoperative telemedicine trial after cardiac surgery and incorporation into practice

ObjectiveThe study objective was to describe the implementation and results of a postoperative telemedicine program for adult cardiac surgery, including a clinical study and an organic postoperative telemedicine program aimed at reducing readmission rates and barriers to care. MethodsPatients undergoing coronary artery bypass grafting consented to enrollment in our Perfect Care study funded by The Duke Endowment including advanced practice provider–led postdischarge telemedicine services with data collection. There were 2 telemedicine visits at days 3 and 10 postdischarge using a live face-to-face video platform. Patients were provided with home wearables for heart rate monitoring, blood pressure cuffs, and scales. The success of the Perfect Care study led to the formation of our organic program, the Tele Heart Care, which was adapted to include a larger patient population while remaining structurally similar. ResultsFifty patients were enrolled prospectively between January and October 2021 in Perfect Care. The 30-day readmission rates for those enrolled was 4% compared with a 16% readmission rate for nonenrolled patients during this period. Furthermore, 36% of enrolled patients received medication modifications to optimize blood pressure, heart rate and rhythm, and fluid-volume status, or to treat infectious symptoms. Tele Heart Care enrolled 203 patients and was associated with a decrease in 30-day readmission rates in all cardiac surgery patients at our institution from 24% to 4% over a 6-month period. ConclusionsAn advanced practice provider–led postdischarge telemedicine program after cardiac surgery can reduce hospital readmission and barriers to care, and improve patient satisfaction. With involvement of multiple stakeholders, a successful program can be launched despite the present state of national health system finances with limited human capital and constrained access to monitoring equipment.

The Evolving Practice of Hospital at Home in the United States.

Hospital at Home (HaH) provides hospital-level services in the home to eligible patients who would otherwise require facility-based hospitalization. In the last two decades, studies have shown that HaH can improve patient outcomes and satisfaction and reduce hospital readmissions. Improved technology and greater experience with the model have led to expansion in the scope of patients served and services provided by the model, but dissemination in the United States has been hampered by lack of insurance coverage until recently. HaH is likely at the tipping point for wide adoption in the United States. To realize its full benefits, HaH will need to continue volume expansion to achieve culture change in clinical practice as facilitated by increased insurance coverage, technological advancements, and improved workforce expertise. It is also essential that HaH programs maintain high-quality acute hospital care, ensure that their benefits can be accessed by hard-to-reach rural populations, and continue to advance health equity.

Hospital Readmissions by Variation in Engagement in the Health Care Hotspotting Trial

Variability in intervention participation within care management programs can complicate standard analysis strategies. To evaluate whether care management was associated with reduced hospital readmissions among individuals with higher participation probabilities. A total of 800 hospitalized patients aged 18 years and older were randomized as part of the Health Care Hotspotting randomized clinical trial, which was conducted in Camden, New Jersey, from June 2014 to September 2017. Data were collected through October 2018. In this new analysis performed between April 6, 2022, and April 23, 2023, the distillation method was applied to account for variable intervention participation. A gradient-boosting machine learning model produced predicted probabilities of engaged participation using baseline covariates only. Predicted probabilities were used to trim both intervention and control populations in an equivalent manner, and intervention effects were reevaluated within study population subsets that were increasingly concentrated with patients having higher participation probabilities. Patients had 2 or more hospitalizations in the 6-month preenrollment period and documented evidence of chronic illness and social complexity. Multidisciplinary teams provided services to patients in the intervention arm for a mean 120 days after hospital discharge. Patients in the control group received usual postdischarge care. Hospital readmission rates and counts 30, 90, and 180 days postdischarge. Of 800 eligible patients, 782 had complete discharge information and were included in this analysis (mean [SD] age, 56.6 [12.7] years; 395 [50.5%] female). In the intent-to-treat analysis, the unadjusted 180-day readmission rate for treatment and control groups was 60.1% vs 61.7% (adjusted odds ratio, 0.95; 95% CI, 0.71-1.28; P = .73) and the mean (SD) number of 180-day readmissions was 1.45 (1.89) vs 1.48 (1.94) (adjusted incidence rate ratio, 0.99, 95% CI, 0.88-1.12; P = .86). Among the population with the highest participation probabilities, the mean (SD) 180-day readmission count was 1.22 (1.74) vs 1.57 (1.74) and the incidence rate ratio attained statistical significance (adjusted incidence rate ratio, 0.74; 95% CI, 0.56-0.99; P = .045). Adjusted odds ratios and adjusted incidence rate ratios for 30- and 90-day outcomes reached statistical significance after population distillation. This secondary analysis of a randomized clinical trial found that care management was associated with reduced readmissions among patients with higher participation probabilities, suggesting that program operation could be improved by addressing barriers to participation and refining inclusion criteria to identify patients most likely to benefit. ClinicalTrials.gov Identifier: NCT02090426.

Defining a path toward improved heart failure care.

Defining a path toward improved heart failure (HF) care is essential, as there is a clear need to improve HF treatment quality, outcomes, and value. This article reviews potential strategies to help improve the quality of HF clinical care and decrease costs. To start, HF phenotyping may be useful in guiding patient treatment, as some phenotypes are associated with higher hospitalization costs and longer length of stay. Identifying and addressing social determinants of health that may be barriers to optimal health may improve management of HF and help to prevent disease progression. In addition, patient-reported outcomes can be useful for evaluating the effectiveness of treatment regimens and assessing which treatments lead to a genuine improvement in quality of life (QOL). Recent innovations in payment reform have seen the implementation of value-based payment (VBP) models over the traditional fee-for-service (FFS) models. FFS models can lead to low-quality care focused on treating illness instead of supporting wellness initiatives. By contrast, VBP models aim to decrease excessive health care costs, thereby increasing incentives to hospitals that deliver high-quality patient care. Further, novel care delivery approaches, such as hospital-at-home and other digital tools, can provide patients with lower-cost care and are associated with improved QOL, including reductions in hospital readmission.

Patch Sensor and Wireless Body Area Network for Disease Detection in Human Body: A Comprehensive Survey

Abstract: This research paper highlights the advancements and applications of Patch Sensor and WBAN, presenting a comprehensive overview of their potential to revolutionise patient care and health management. Fitness wearables that track the personal health status have become very popular in the past years. Sensor industry wants to integrate technological advances into products for the consumer market. Sensors can be embedded in smart clothing to collect physiological data in an unobtrusive way. The integration of patch sensors with Wireless Body Area Network (WBAN) technology has emerged as a transformative approach in healthcare and medical monitoring. Patch sensors are thin, flexible devices that adhere to the skin, capable of collecting vital physiological data, such as heart rate, temperature, respiratory rate, and motion, with exceptional accuracy and non-invasiveness. When combined with WBAN, which facilitates seamless communication between wearable sensors and a central monitoring system, real-time health data can be efficiently transmitted, analysed, and acted upon. The integration of Patch Sensor and WBAN has unlocked numerous applications, including continuous remote patient monitoring, early disease detection, and personalised healthcare. Its deployment in chronic disease management allows healthcare professionals to access patients' data remotely, enabling timely interventions and reducing hospital readmissions. Moreover, athletes and fitness enthusiasts can benefit from performance optimization, injury prevention, and recovery tracking through this technology.

The Impact of Transitional Care for Geriatric Patients with Chronic Diseases

Indonesia has gradually become an aging society as socio-demographic changes happen in the last decades, affected the health care system in many countries. An increased hospital readmission rate and prolonged hospitalization in elderly patients due to chronic illness have been a new challenge. A comprehensive plan to ensure the coordination and continuity of health care after hospital discharge is needed to improve the sustainability of long-term management. In 2021, literature was searched on the PubMed, ScienceDirect, and Cochrane electronic databases with keywords for transitional care, geriatric, and chronic disease. Inclusion criteria were randomized controlled trial (RCT), systematic review, or meta-analysis studies that implemented transitional care intervention (TCis) for people older than 60 with chronic diseases. Studies were limited to those published in the past ten years and published in Bahasa/English. Critical appraisal was assessed using the PRISMA guideline. We identified 107 records. Seven articles met the inclusion criteria. Outcome assessments were conducted from one to 12 months after discharge. TCis were divided into 3 points: before discharge, after discharge at home, and throughout the entire period. Readmission was measured in most studies (n=7), mortality (n=4), and emergency department (ED) visit (n=3). Most of the study showed a positive impact in the intervention groups (IG) compared to the control groups (CG). Transitional care is beneficial for geriatrics with chronic disease as it reduces hospital readmission rates, mortality, and ED visit. Five domains should be addressed to have effective transitional care: comprehensive assessment, planning and communication, support for self-care and the caregiver, access facilitation, and a competent healthcare team.

Educación terapéutica en insuficiencia cardiaca mediante e-Salud: revisión sistemática

ObjectiveTo provide the best scientific evidence available on the effectiveness of therapeutic education programs through digital health in patients with heart failure. DesignSystematic review of randomized clinical trials. Data sourcesSix databases were included due to their relevance in Health Sciences: PubMed, EMBASE, Scielo, Cochrane, CINAHL, and Web of Science. Selection of studiesIn English and Spanish, studies carried out between 2018 and 2023 were selected. After evaluating the methodological quality of the studies, the Jadad tool was used to discriminate those that did not meet said quality. In total, 8 articles from 6 different countries were included. Data extractionThe review and analysis of the documents were carried out by independent pairs. The Cochrane tool for RoB 2 randomized clinical trials was used to assess the risk of bias. ResultsAll the applications had therapeutic education, it was also assessed that they had monitoring, evaluation of signs and symptoms, drug titration, and professional follow-up through the application. ConclusionThis review reveals the significant impact of therapeutic education in increasing patient knowledge, reducing hospital readmissions, and improving functional status and self-care. This makes digital health a valuable tool to complement nursing care in patients with heart failure.

Management of hospital admission, patient information and education, and immediate preoperative care.

An increasing proportion of surgical procedures involves elderly and frail patients in high-income countries, leading to an increased risk of postoperative complications. Complications significantly impact patient outcomes and costs, due to prolonged hospitalization and loss of autonomy. Consequently, it is crucial to evaluate preoperative functional status in older patients, to tailor the perioperative plan, and evaluate risks. The hospital environment often exacerbates cognitive impairments in elderly and frail patients, also increasing the risk of infection, falls, and malnutrition. Thus, it is essential to work on dedicated pathways to reduce hospital readmissions and favor discharges to a familiar environment. In this context, the use of wearable devices and telehealth has been promising. Telemedicine can be used for preoperative evaluations and to allow earlier discharges with continuous monitoring. Wearable devices can track patient vitals both preoperatively and postoperatively. Preoperative education of patient and caregivers can improve postoperative outcomes and is favored by technology-based approach that increases flexibility and reduce the need for in-person clinical visits and associated travel; moreover, such approaches empower patients with a greater understanding of possible risks, moving toward shared decision-making principles. Finally, caregivers play an integral role in patient improvement, for example, in the prevention of delirium. Hence, their inclusion in the care process is not only advantageous but essential to improve perioperative outcomes in this population.

Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care.

Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

The Perioperative Use of Levosimendan as a Means of Optimizing the Surgical Outcome in Patients with Severe Heart Insufficiency Undergoing Cardiac Surgery.

Postoperative myocardial dysfunction following cardiac surgery is a relatively common occurrence. Levosimendan, a calcium sensitizer and inotropic drug, has shown potential in improving outcomes for patients with low preoperative ejection fraction (EF) and myocardial dysfunction after cardiac surgery. This study aims to evaluate the efficacy of levosimendan in optimizing the surgical outcome for such patients. A retrospective analysis was conducted on 314 patients with preoperative severe heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while a comparable group of 130 patients received conventional treatment. The use of levosimendan demonstrated several advantages in postoperative outcomes. It significantly improved short- and long-term survival rates after cardiac surgery, enhanced hemodynamic stability, reduced the requirement for inotropic support, and facilitated faster weaning from ventilator support. Patients who received levosimendan reported reduced angina and dyspnea symptoms, as well as fewer postoperative arrhythmias. Furthermore, levosimendan helped minimize myocardial injury inevitable after cardiac surgery. The levosimendan group also exhibited a notable reduction in hospital readmissions. This study provides evidence of several benefits associated with the perioperative use of levosimendan. However, further prospective randomized studies are warranted to standardize and comprehensively document the other perioperative therapies, in order to validate these findings and establish stronger conclusions.

Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature.

Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.

Internet of Medical Things Application in King Hamad University Hospital

Background: The Internet of Medical Things (IoMT) is a network of medical devices and applications that are connected to the internet, allowing healthcare providers to remotely monitor and manage patient health. King Hamad University Hospital (KHUH) is a tertiary care hospital in Bahrain that has implemented various IoMT applications to improve patient care. Methods: The aim of this study is to investigate the application of Internet of Medical Things (IoMT) in King Hamad University Hospital (KHUH) and its impact on patient care and hospital operations The study will be conducted at KHUH, which is a tertiary care hospital located in Bahrain. KHUH, accommodates 739 bed in all services. (In- patients including isolation rooms: 348, Out-patient clinics: 242, Other services: 149). That provides specialized medical services to patients from Bahrain and neighboring countries. Results: The survey results showed that the most commonly used IoMT applications were remote monitoring devices for vital signs, telemedicine platforms for virtual consultations, and electronic health records for patient data management. Healthcare providers reported that these applications were effective in improving patient outcomes, reducing hospital readmissions, and increasing efficiency in healthcare delivery. However, some challenges were identified during implementation, such as technical issues with connectivity and data security concerns. Conclusion: The implementation of IoMT applications in KHUH has shown promising results in improving patient care and healthcare delivery. However, ongoing efforts are needed to address the challenges faced during implementation to ensure the sustainability and scalability of these technologies. Further research is also needed to evaluate the long-term impact of IoMT on patient outcomes and healthcare costs.

Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review

BackgroundPatients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended.AimTo identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development.MethodsA systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically.ResultsA total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided.ConclusionVery few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted—in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other’s experiences.Trial registrationThe review was registered in PROSPERO with registration number CRD42022339523.

Reducing hospital readmissions amongst people experiencing homelessness: a mixed-methods evaluation of a multi-disciplinary hospital in-reach programme

IntroductionPeople experiencing homelessness are at increased risk of experiencing ill-health. They are often readmitted to hospital after discharge, usually for the same or similar reasons for initial hospitalisation. One way of addressing this issue is through hospital in-reach initiatives, which have been established to enhance the treatment and discharge pathways that patients identified as homeless receive after hospital admission. Since 2020, the Hospital In-reach programme (which involves targeted clinical interventions and structured discharge support) has been piloted in two large National Health Service (NHS) hospitals in Edinburgh, United Kingdom (UK). This study describes an evaluation of the programme.MethodsThis evaluation used a mixed method, pre-post design. To assess the effect of the programme on hospital readmission rates from baseline (12 months pre-intervention) and follow-up (12 months post-intervention), aggregate data describing the proportions of homeless-affected individuals admitted to hospital during the evaluation period were analysed using Wilcoxon signed rank test, with level of significance set at p = 0.05. Qualitative interviews were conducted with fifteen programme and hospital staff (nurses, general practitioners, homeless link workers) to assess the processes of the programme.ResultsA total of 768 referrals, including readmissions, were made to the In-reach programme during the study period, of which eighty–eight individuals were followed up as part of the study. In comparison to admissions in the previous 12 months, readmissions were significantly reduced at 12 months follow-up by 68.7% (P = 0.001) for those who received an in-reach intervention of any kind. Qualitative findings showed that the programme was valued by hospital staff and homeless community workers. Housing services and clinical staff attributed improvements in services to their ability to collaborate more effectively in secondary care settings. This ensured treatment regimens were completed and housing was retained during hospital admission, which facilitated earlier discharge planning.ConclusionsA multidisciplinary approach to reducing readmissions in people experiencing homelessness was effective at reducing readmissions over a 12-month period. The programme appears to have enhanced the ability for multiple agencies to work more closely and ensure the appropriate care is provided for those at risk of readmission to hospital among people affected by homelessness.

Effectiveness of a home-based telesurveillance program in reducing hospital readmissions in older patients with chronic disease: The eCOBAHLT randomized controlled trial.

Given that chronic, long-term conditions are increasingly common in older patients, the impact of telesurveillance program on clinical outcomes is uncertain. This study aimed to evaluate the feasibility and effectiveness of a 12-month remote monitoring program in preventing rehospitalizations in older patients with two or more chronic diseases returning home after hospitalization. We conducted a multicenter randomized controlled trial in two parallel groups to evaluate the remote monitoring system. Elderly patients with chronic diseases (at least two comorbidities) aged 65 years or older and discharged home after acute hospital care for a chronic disease were randomized to receive a home telemonitoring program (intervention group, n = 267) or conventional care (control group, n = 267). The remote home monitoring program was an online biometric home life analysis technology (e-COBAHLT) with tele-homecare/automation and biometric sensors. The eCOBALTH intervention group received the automation sensors containing chronic disease clinical factor trackers to monitor their biometric parameters and detect any abnormal prodromal disease decompensation by remote monitoring and providing geriatric expertise to general practitioners. The usual care group received no eCOBALTH program. In both groups, baseline visits were conducted at baseline and the final visit at 12 months. The primary outcome was the incidence of unplanned hospitalizations for decompensation during the 12-month period. Among 534 randomized participants (mean [SD] age, 80.3 [8.1] years; 280 [52.4%] women), 492 (92.1%) completed the 12-month follow-up; 182 (34.1) had chronic heart failure, 115 (21.5%) had stroke, and 77 (14.4%) had diabetes. During the 12-month follow-up period, 238 patients had at least one unplanned hospitalization for decompensation of a chronic disease: 108 (40.4%) in the intervention group versus 130 (48.7%) in the control group (P = 0.04). The risk of rehospitalization was significantly reduced in the intervention group (age- and sex-adjusted relative risk: 0.72, 95% 95% confidence intervals 0.51-0.94). A 12-month home telemonitoring program with online biometric analysis using Home life technology combining telecare and biometric sensors is feasible and effective in preventing unplanned hospitalizations for chronic disease decompensation in elderly patients with chronic diseases at high risk for hospitalizations.

The Path to Sustainable Healthcare: Implementing Care Transition Teams to Mitigate Hospital Readmissions and Improve Patient Outcomes.

Introduction Hospital readmissions within 30 days suggest care quality issues and increased mortality risks. They result from ineffective initial treatment, poor discharge planning, and inadequate post-acute care. These high readmission rates harm patient outcomes and financially strain healthcare institutions, inviting penalties and discouraging potential patients. Enhancing inpatient care, care transitions, and case management is crucial to lowering readmissions. Our research underscores the role of care transition teams in reducing readmissions and financial stress in hospitals. By consistently applying transition strategies and focusing on high-quality care, we can improve patient outcomes and ensure hospital success in the long run. Methods This two-phase study investigated readmission rates and risk factors in a community hospital from May 2017 to November 2022. Phase 1 determined a baseline readmission rate and identified individual risk factors using logistic regression. In phase 2, a care transition team addressed these factors by providing post-discharge patient support through phone calls and assessing social determinants of health (SDOH). Readmission data from the intervention period was compared to baseline data using statistical tests. Data, including demographics, medical conditions, and comorbidities, were collected via electronic medical records and the International Classification of Diseases (ICD-10 codes). The study focused on patients aged 20-80 with readmissions within 30 days. Exclusions were made to minimize confounding effects from unmeasured comorbidities and ensure an accurate representation of factors affecting readmissions. Results In the study's initial phase, 74,153 patients participated, with an 18% mean readmission rate. Women accounted for 46% of readmissions, and the white population had the highest rate (49%). The 40-59 age group showed a higher readmission rate than other age groups, and certain health factors were identified as risk factors for 30-day readmission. In the subsequent phase, a care transition team intervened with high-risk groups using an SDOH questionnaire. They contacted 432 patients, resulting in a reduced overall readmission rate of 9%. The 60-79 age group and the Hispanic population experienced higher readmission rates, and the previously identified health factors remained significant risk factors. Conclusion This study emphasizes the crucial role of care transition teams in reducing hospital readmission rates and easing the financial strain on healthcare institutions. By identifying and addressing individual risk factors, the care transition team effectively lowered the overall readmission rate from 18% to 9%. Continually implementing transition strategies and prioritizing high-quality care focused on minimizing readmissions are essential for improving patient outcomes and long-term hospital success. Healthcare providers should consider utilizing care transition teams and social determinants of health assessments to better understand and manage risk factors and tailor post-discharge support for patients at higher risk of readmission.