Transitional Care Program Research Articles

The Role of Ultrasound-Guided Therapeutic Paracentesis in an Outpatient Transitional Care Program: A Case Series.

Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.

Descriptive Analysis and Profile of Health Care Transition Services Provided to Adolescents and Emerging Adults in the Movin' On Up Health Care Transition Program

Global efforts are underway to develop, implement and test health care transition (HCT) models of care. Most studies have focused on the transfer of care models. In contrast, the nurse-led interdisciplinary HCT model, Movin' On Up, provides comprehensive HCT services beginning in early adolescence. A retrospective analysis was conducted of data extracted from HCT records of 146 adolescents and emerging adults with spina bifida (with a mean age of 13.91 years) who were provided services in the Movin' On Up HCT program. Data were categorized based on the Health Care Transition Research Consortium HCT model and the Omaha System framework and as to type of direct HCT services provided by the HCT Specialist and nurse-led interdisciplinary team conferences conducted. Findings revealed that the scope of services provided represented the scope of comprehensive needs beyond those associated with the transfer of care.

Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program.

Postdischarge medication management services have been shown to reduce the incidence of medication-related problems during the transition from inpatient to outpatient care. A pharmacist-run transition of care (TOC) program has been developed to reduce the unplanned readmissions of a high-risk managed Medicaid population after hospitalization. To estimate the budget impact of adding an outpatient pharmacy-based TOC program to a medical benefit from the payer perspective. A budget impact analysis was conducted using a decision-tree model developed in Microsoft Excel. The effect on inpatient and total health care costs from the payer perspective was estimated for the 2-year period following initial hospital discharge. Inputs were based on a total plan population of 240,000 lives, with a high-risk population of 7.5%, of whom 37% were hospitalized and potentially qualified for TOC services, resulting in an eligible population of 6,660 patients. The TOC program was assumed to initially cover 30% of the eligible population, with expansion to 60% over the 2 years. We previously reported that this program reduced the risk of readmission by 32% within 6 months and saved the health plan $2,139 per patient referred to the program, inclusive of program cost, compared with patients receiving usual discharge care. Sensitivity analyses were performed to test the impact of uncertainty of model inputs on the results, with the cost of TOC services ranging from $99 to $2,000 per patient referred. The model showed that the TOC program was cost saving at over $3 per member per month in the first 6 months, which translates to over $25 million in total health care cost savings over 2 years. These results were primarily driven by the estimated reduction in inpatient costs associated with the program, which were estimated at $20 million over the 2 years. Sensitivity analyses illustrated that within all the reasonable ranges of model input parameters, including the upper limit of TOC services set to $2,000 per patient referred, the TOC program resulted in cost savings to the health plan. The TOC program resulted in potential cost savings of over $25 million to the managed Medicaid plan over a period of 2 years, corresponding to over $4 per member per month. Funding for this study was contributed by the Komoto Family Foundation, which provided fellowships to Ni and McCombs during the time of this study. Colayco is employed by Synergy Pharmacy Solutions and by the Komoto Family Foundation. Hashimoto and Komoto are employed by Synergy Pharmacy Solutions. Gowda and Wearda report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Ni, Colayco, and McCombs, along with the other authors. Hashimoto, Komoto, and Wearda took the lead in data collection, assisted by Ni, Colayco, and Gowda. Data interpretation was performed by Ni, Colayco, and McCombs, along with the other authors. The manuscript was written by Ni and Colayco and revised by Gowda and McCombs, along with the other authors.

The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review.

The objective was to identify and synthesize the best available evidence on the impact of transitional care programs on various forms of health services utilization in community-dwelling older adults. There is growing evidence that transitional care programs can help address important challenges facing health care systems and our increasing older adult population in many countries by reducing unnecessary health service utilization. There is a need for a systematic review of the research evaluating the impact of transitional care programs on hospital and other health service usage. The review included studies on community-dwelling adults age 60 and over with at least one medical diagnosis, and which evaluated the outcomes of transitional care programs on health system utilization of older adults. The outcomes for this review were hospital usage including admissions and readmissions, emergency department usage, primary care/physician usage, nursing home usage, and home health care usage. The review considered experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, and case-control studies. A three-step search was utilized to find published and unpublished studies conducted in any country but reported in English. Six electronic databases were searched from inception of the database to May, 2016. A search for unpublished studies was also conducted. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. Quantitative data were extracted from included studies independently by the two reviewers using the standardized Joanna Briggs Institute data extraction tools. Due to the methodological heterogeneity of the included studies, a comprehensive meta-analysis for all outcomes was not possible. Meta-analysis was conducted for rehospitalization at 30, 90 and 180 days. A narrative summary of other quantitative findings was conducted. Twenty-three studies met the inclusion criteria and were included in the review. Nineteen of the studies were randomized controlled trials and four were case control studies, involving 20,997 participants in total with a mean age of 76. Meta-analysis found that transitional care significantly reduced hospital readmission rates at 30 days (odds ratio [OR] 0.75, 95% confidence intervals [CIs] 0.62-0.91, p < 0.01), 90 days (OR 0.77, 95% CIs 0.59-1.02, p = 0.04), and 180 days (OR 0.67, 95% CIs 0.46-0.99, p < 0.01). Narrative synthesis indicated little impact of transitional care on emergency department and nursing home usage, increased use of primary care/physician usage, and decreased home health care usage. Based on a review of 23 studies conducted in the USA, Hong Kong, Canada, Germany, the Netherlands, Sweden and Switzerland, we identified four major conclusions. First, transitional care reduces rehospitalization rates over time, with the largest effects seen at 30 days. Second, transitional care may increase the utilization of primary care services and thus have a favourable impact on preventative care. Third, transitional care may reduce home health usage. Fourth, transitional care interventions of one month or less appear to be as effective as longer interventions in reducing hospital usage.

Effects of a nurse-led transitional care programme on readmission, self-efficacy to implement health-promoting behaviours, functional status and life quality among Chinese patients with coronary artery disease: A randomised controlled trial.

To examine the effectiveness of a nurse-ledtransitional careprogramme on readmission, self-efficacy to implement health-promoting behaviours, functional status and life quality among Chinese patients with coronary artery disease. Coronary artery disease is a major cause of mortality in China. Transitional care could help to ensure improved patient outcomes. Nevertheless, our knowledge of how to perform transitional care for patients with coronary artery disease is insufficient in mainland China. Randomised controlled trial. The nurse-led transitional care intervention in the experimental group adopted the Omaha system and Pender's health-promoting model as its frameworks. The control group received a comparable length routine care and follow-up contacts. Evaluations were conducted at baseline before discharge and after 7months after discharge using hospital readmission rate, self-rated abilities for health practices scale and Seattle Angina Questionnaire for functional status and life quality. Data were collected between March 2014-October 2014. Compared with the control group, participants in the experimental group showed greater self-efficacy to implement health-promoting behaviours, more angina stability, less angina frequency, more satisfaction with treatment and better quality of life. The difference in readmission rate and physical limitations was not significant between the two groups. This study provides evidence for the effectiveness of a nurse-led transitional care programme in improving the ability to implement health-promoting behaviours, the functional status and life quality among Chinese patients with coronary artery disease. The nurse-led transitional care programme is helpful for coronary artery disease patients to promote their effective transfer from hospital to community and provide an evidence for nursing managers to train their nurses for transitional care knowledge and skills.

Peer support as a strategy for reducing hospital readmissions among older adults with chronic medical illness and depression.

Reducing hospital readmissions has become a national priority, and there has been a strong push to identify strategies that reduce the number of hospital readmissions for high-risk patients. Recent evidence suggests adding peer support to Care Transitions Interventions may reduce hospital readmissions among older adult patients; however there is a dearth of research examining mechanisms through which added peer support may impact outcomes. This paper qualitatively examined the mechanisms through which peer support impacts outcomes after hospitalization from the perceptions of diverse older adults (N=11) recently discharged from the hospital living with a chronic illness and co-occurring clinical depression. Participants were recruited from Tampa General Hospital located in Tampa Florida in the United States. Through thematic analysis, we identified three mechanisms through which peer support may impact hospital readmissions: increased self-efficacy in self-management of disease, connection to community resources and improved mental health literacy. This study suggests that peer support is a valuable approach towards enhancing the benefit and reach of evidence-based Care Transitions Programs.

Older Adults' Perceptions of the Built Environment and Associations with Frailty: A Feasibility and Acceptability Study.

It is essential to evaluate frail older adults understanding and execution of survey tools to improve data quality and accurate representation in research. The study tested the feasibility and acceptability of a survey that assesses various measures of functional status in frail older people. The study evaluated: 1) recruitment rate; 2) time to complete questionnaires and difficulties encountered; and 3) acceptability by participants. Validated tools including: FRAIL Scale, EuroQoL 5D-5L, Charlson's Comorbidities Index, Baecke's Physical Activity Questionnaire, Life-Space Assessment, Katz and Lawton ADL and NEWS Walkability Scale were assessed. Twenty-five older patients (63% recruitment rate) of a post-acute restorative program (residential Transition Care Program) in Adelaide, South Australia were interviewed. Although not statistically different, time to complete the overall questionnaire differed between robust, pre-frail and frail participants. Overall, the survey was considered acceptable and feasible, with consideration with NEWS and Life-Space assessment regarding length, phrasing and layout.

Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program.

Most older adults with hip fracture surgery experience functional decline (FD), causing devastating outcomes. However, few studies have examined the effects of nursing interventions to reduce FD for them. The aim of the study was to evaluate an individualized transitional care program (ITCP) to reduce FD for older adults with hip arthroplasty. The study was quasiexperimental, with a nonequivalent control group design. A total of 37 participants scheduled for hip arthroplasty were recruited-21 in the experimental and 16 in the control group. Two weeks following surgery (i.e., just prior to discharge), the ITCP group displayed less fear of falling than the usual care group. Moreover, the experimental group displayed objectively less FD with increased activities of daily living and Timed Up and Go scores, 6 weeks after hip arthroplasty. This study provides evidence of the effectiveness of nurse-led rehabilitative practices to reduce FD in older adults with hip arthroplasty. The ITCP promoted individual physical functioning for older adults with hip arthroplasty. This study results can aid healthy transitions of elderly patients with other various diseases.

Symptoms Reported by Frail Elderly Adults Independently Predict 30-Day Hospital Readmission or Emergency Department Care.

To assess the degree to which self-reported symptoms predict unplanned readmission or emergency department (ED) care within 30 days of high-risk, elderly adults enrolled in a posthospitalization care transition program (CTP). Retrospective cohort study. Posthospitalization CTP at Mayo Clinic, Rochester, Minnesota, from January 1, 2013, through March 3, 2015. Frail, elderly adults (N = 230; mean age 83.5 ± 8.3, 46.5% male). Charlson Comorbidity Index (CCI) and self-reported symptoms, measured using the Edmonton Symptom Assessment System (ESAS), were ascertained upon CTP enrollment. Mean CCI was 3.9 ± 2.3. Of 51 participants returning to the hospital within 30 days of discharge, 13 had ED visits, and 38 were readmitted. Age, sex, and CCI were not significantly different between returning and nonreturning participants, but returning participants were significantly more likely to report shortness of breath (P = .004), anxiety (P = .02), depression (P = .02), and drowsiness (P = .01). Overall ESAS score was also a significant predictor of hospital return (P = .01). Four self-reported symptoms and overall ESAS score, but not CCI, ascertained after hospital discharge were strong predictors of hospital return within 30 days. Including symptoms in risk stratification of high-risk elderly adults may help target interventions and reduce readmissions.

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population.

Cost-Effectiveness of a Care Transitions Program in a Multimorbid Older Adult Cohort.

Facing penalties for preventable 30-day hospital readmissions, many provider groups have implemented programs to remedy this problem, but the cost efficacy and value of such programs are not well delineated. The objective was to compare total cost of care over 30 days of individuals enrolled in the Mayo Clinic Care Transitions (MCCT) program and individuals not enrolled. Retrospective cohort study using secondary data analysis of a previously published cohort study. Mayo Clinic, Rochester, Minnesota. MCCT participants (n = 363) and individuals in a propensity-matched referent cohort (n = 365). MCCT program enrollment. The primary outcome was total cost of care over 30 days after hospital discharge. A 2-part modeling strategy was used to analyze 30-day costs: whether individuals had non-zero costs during the 30 days after discharge and a generalized linear model for individuals who incurred costs. Potential heterogeneous effects of the MCCT program were examined according to decile of 30-day costs using quantile regression. Mean age was 83 in both groups. Adjusted mean 30-day cost after hospitalization was $3,363 (95% confidence interval (CI) = $2,512-4,213) in the MCCT group and $4,161 (95% CI = $3,096-5,226) in the control group (P = .25). Cost savings of $2,744 (P = .008) at the eighth decile and $3,388 (P = .20) at the ninth decile were demonstrated. Thus, the only statistically significant differences were in the post hoc subgroup analysis in the highest-cost subgroups. We did not find a difference in overall mean costs between the MCCT group and the control group, although intervention participants in the upper deciles of costs appeared to experience lower costs than controls. A larger study cohort might better determine the value of the intervention.

Medication Use Leading to Hospital Readmission in Frail Elders

Abstract Frail multimorbid elders are at high risk for hospital readmission and can benefit from dedicated care transitions programs. Nonetheless, some patients remain at disproportionately heightened risk. In this retrospective study of 717 frail multimorbid community-dwelling elders (mean age = 83 years) enrolled in a care transitions program, we assessed the effect of specific medications and postdischarge medication changes on 30-day readmission. Patients treated with opioids, anticholinergic agents, or antihistamines and those requiring ≥ 4 medication changes after hospital discharge were at a significantly greater risk. This knowledge provides nurse practitioners an opportunity to individualize and improve the care of this vulnerable population.

The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review.

The Affordable Care Act of 2010 set forth payment models that provided $10 billion to incent the health care system in developing innovative programs that target reform, including transitional care to reduce preventable readmissions. While transitional care programs exist, US hospitals remain challenged, with 1 in 5 readmissions within 30 days. This systematic review examined the effectiveness of select evidence-based transitions-of-care interventions on reducing 30-day readmission rates, reducing emergency room visits, and reducing mortality rates. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines formed the framework for this systematic review. Key study characteristics informed the eligibility criteria and search strategy. Two reviewers independently appraised selected studies using the Critical Appraisal Skills Programme tools. Included studies were summarized and synthesized in order to draw conclusions across studies. Interventions are aimed at reducing the readmission rate of the adult general medical population. The population of focus in this review includes patients at risk of avoidable readmissions, which includes patients requiring higher levels of care secondary to complications that can contribute to higher mortality after discharge from an acute care setting. The findings of this review support the use of transitions-of-care interventions such as tailored discharge planning and postdischarge phone calls.

Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study

BackgroundAdapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP.MethodsThis is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA.DiscussionThe use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.

Modeling the impact of care transition programs on patient outcomes and 30 day hospital readmissions

The increasing adoption of care transition programs – interventions designed to reduce hospital readmissions – has introduced a new challenge of evaluating such programs, i.e., assessing their impact on patient outcomes and care quality. This is difficult given the limited availability of program outcome data and analytical feedback exchange between providers. Moreover, the temporal nature of the effects of scheduled interventions on patient health raises the question of selecting and applying methodological tools appropriate for scientific research in this area. Our aim is to provide such methodological guidance and assist analysts, healthcare providers, and policy makers with extracting meaningful insights regarding the impact of care transition programs based on available data. We explore two well-known modeling approaches, Cox models and Markov chains, and using an illustrative example, demonstrate how they can be translated into informative analytic models with sufficient flexibility to analyze programs with diverse structures. We show that Cox Proportional Hazard models are particularly useful for identifying variables with the greatest impact on readmissions and quantifying the benefits of patient participation in a readmission reducing program. Extended Cox models provide an understanding of the effects of influential variables on readmissions as they change throughout the recovery period, allowing assessment of the relative benefits of care transition programs on different patient populations at specific times following a hospital discharge. Discrete Time Markov Chain models are particularly useful for assessing the impact of care transition programs in terms of expected time to readmission, facilitating the comparison of alternative program designs on patient outcomes.

Evaluation of a transitional care programme for frail older adults and the effectiveness for the oldest old

Introduction: Older adults with multimorbidity, aged 70 years and older, experience a complex of both medical and social problems and frequently require continuous care in multiple settings. They move between acute and non-acute care settings, such as hospitals, home, intermediate care unit, primary care center, nursing home and hospice. It is within that context, that the transitional care programme for this group has been developed in the IJsselland hospital in the Netherlands, and will be evaluated. In this programme the Transmural Care Bridge is incorporated. The programme: The identification of seniors at risk starts at the Emergency Department with the ISAR- HP, the identification of seniors at risk- hospitalized. Patients at high risk for functional decline will fill out a triage questionnaire with their informal caregivers developed by the Geriatricians of the hospital. In all cases a registered nurse on the ward were the patient is admitted will start with screening on delirium, malnutrition, ADL functions, mobility and fall risk. If nessecary the geriatric consultation team will visit the patient and a systematic comprehensive geriatric assessment (CGA) will be done. The geriatrician will develop a care plan. In the programme one day before discharge from hospital a community nurse (CN) visits the patient inside the hospital and within 48 hours after discharge from hospital and after 2, 6, 12 and 24 weeks. Main issues during these visits are medication safety, appropriateness of care arranged during hospital admission resources, social network and support for the informal caregiver. The CN will discuss the care plan with the General Practitioner (GP) of the patient. In a prospective cohort study 100 older patients, 50 patients before and 50 patients a after the start of this programme, are asked to fill out a questionnaire at the start of the program in het hospital, and after one and three months after discharge from hospital, to measure morbidity, functional limitations, cognitive functioning, social functioning, self-perceived health, self-perceived quality of life, experiences, GP visits and admissions. Also the effectiveness of the program on self-management abilities will be measured by the CN through the Self Sufficiency Matrix. 30 professionals inside and outside the hospital who provide care for this group of older adults, specialist, nurses, general practitioners and community nurses will be asked to provide their perspectives on the programme and on inter-professional collaboration. Effectiveness for the oldest old: Because preliminary research findings showed that many people aged 85 years and older, who we consider in this study as the oldest old, said they felt lonely, useless, lost spouses, friends and sometimes children and sometimes were waiting to die, an additional question arose about how the oldest old would percieve this care programme and if this would meet their needs. This question will be adressed by in depth interviews with the oldest old. Aim: This research project aims to contribute to changes in transitional care for older adults who are admitted to the hospital and add to the current body of knowledge of the perspectives of the oldest old on their care.

Reducing Readmissions: Nurse-Driven Interventions in the Transition of Care From the Hospital.

Transitions of care (TOC) from hospitals is a continuing focus for quality improvement to reduce readmissions. Sufficient resources to offer interventions remain an issue for hospitals, leading to efforts to target high-risk patients and identify effective interventions. Describe and measure effects, hospital-wide and among high-risk patients, of a multifaceted TOC program on 30-day readmissions in a 441-bed acute care community hospital. Pre-post TOC intervention examining 30-day readmission rates during planning, implementation, and intervention years compared to baseline. Patient characteristics and services received by patients targeted for TOC individualized interventions during hospitalization and after discharge were retrieved from medical records and compared over 4 years during which the intervention was planned and implemented. Summary hospital-wide readmission rates reduced from 11.8% during planning (2011), 12.0% during implementation (2012), to 11.4% during intervention (2013) compared to 13.7% at prestudy baseline (2010; p < .001). TOC program patients were mostly identified by clinician referral (66.7%) rather than computer-generated risk at admission (32.3%), and nearly one-third (30.6%) were readmitted within 30 days of release. Reductions in readmissions were achieved using a multifaceted approach with efforts at admission, predischarge, and postdischarge in a community hospital. Having clinical staff involved in TOC program is important in both patient identification and interventions to reduce readmissions.

The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities.

Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.

Transitional Care to Reduce Cardiac Readmissions: 5-Year Results from the BRIDGE Clinic

High hospital readmission rates contribute to rising health care costs and lower quality of care, particularly in cardiac patients. Transitional care programs that expedite post-discharge visits have the potential to improve this problem. This study examined the effectiveness of one such program, Bridging the Discharge Gap Effectively (BRIDGE), a single-visit, nurse-practitioner-led, cardiac transitional care program.

Targeting the Correct Population When Designing Transitional Care Programs for Medicare Patients Hospitalized With Heart Failure

This study uses data from a large academic medical center to estimate the accuracy of the criteria used by Medicare to represent the burden of hospitalizations for heart failure.