Optimizing transitions of care to reduce rehospitalizations
ABSTRACTTransitions of care—when patients move from one health care facility to another or back home—that are poorly executed result in adverse effects for patients. Fortunately, programs can be implemented that enhance collaboration across care settings and improve outcomes including reducing hospital readmission rates.
KEY POINTS
- Traditional health care delivery models typically do not have mechanisms in place for coordinating care across settings, such as when a patient goes from the hospital to a skilled nursing facility or to home.
- Transitions can fail, leading to hospital readmission, because of ineffective patient and caregiver education, discharge summaries that are incomplete or not communicated to the patient and the next care setting, lack of follow-up with primary care providers, and poor patient social support.
- A number of programs are trying to improve transitions of care, with some showing reductions in hospital readmission rates and emergency department visits.
- Successful programs use multiple interventions simultaneously, including improved communication among health care providers, better patient and caregiver education, and coordination of social and health care services.
The STAAR initiative
The STAAR initiative (State Action on Avoidable Re-hospitalizations)56 was launched in 2009 by the Institute for Healthcare Improvement with the goal of reducing avoidable readmissions in the states of Massachusetts, Michigan, and Washington. Hospital teams focus on improving:
- Assessment of needs after hospital discharge
- Teaching and learning
- Real-time hand-off communication
- Timely follow-up after hospital discharge.
As yet, no published studies other than case reports show a benefit from STAAR.57
The Care Transitions Program
The Care Transitions Program,58 under the leadership of Dr. Eric Coleman, aims to empower patients and caregivers, who meet with a “transition coach.” The program provides assistance with medication reconciliation and self-management, a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, timely outpatient follow-up with primary or specialty care, a list of red flags to indicate a worsening condition, and instructions on proper responses.
A randomized controlled trial of the program demonstrated a reduction in hospital readmissions at 30, 90, and 180 days, and lower hospital costs at 90 and 180 days.59 This approach also proved effective in a real-world setting.60
The Transitional Care Model
Developed by Dr. Mary Naylor and colleagues, the Transitional Care Model61 also aims at patient and family empowerment, focusing on patients’ stated goals and priorities and ensuring patient engagement. In the program, a transitional care nurse has the job of enhancing patient and caregiver understanding, facilitating patient self-management, and overseeing medication management and transitional care.
A randomized controlled trial demonstrated improved outcomes after hospital discharge for elderly patients with complex medical illnesses, with overall reductions in medical costs through preventing or delaying rehospitalization.62 A subsequent real-world study validated this approach.63
The Bridge Model
The Illinois Transitional Care Consortium’s Bridge Model64 is for older patients discharged home after hospitalization. It is led by social workers (“bridge care coordinators”) who address barriers to implementing the discharge plan, coordinate resources, and intervene at three points: before discharge, 2 days after discharge, and 30 days after discharge.
An initial study showed no impact on the 30-day rehospitalization rate,65 but larger studies are under way with a modified version.
Guided Care
Developed at the Johns Hopkins Bloomberg School of Public Health, Guided Care66 involves nurses who work in partnership with physicians and others in primary care to provide patient-centered, cost-effective care to patients with multiple chronic conditions. Nurses conduct in-home assessments, facilitate care planning, promote patient self-management, monitor conditions, coordinate the efforts of all care professionals, and facilitate access to community resources.
A cluster-randomized controlled trial found that this program had mixed results, reducing the use of home health care but having little effect on the use of other health services in the short run. However, in the subgroup of patients covered by Kaiser-Permanente, those who were randomized to the program accrued, on average, 52% fewer skilled nursing facility days, 47% fewer skilled nursing facility admissions, 49% fewer hospital readmissions, and 17% fewer emergency department visits.67
The GRACE model
The GRACE model (Geriatric Resources for Assessment and Care of Elders)68 was developed to improve the quality of geriatric care, reduce excess health care use, and prevent long-term nursing home placement. Each patient is assigned a support team consisting of a nurse practitioner and a social worker who make home visits, coordinate health care and community services, and develop an individualized care plan.
In one study,69 GRACE reduced hospital admission rates for participants at high risk of hospitalization by 12% in the first year of the program and 44% in the second year. GRACE participants also reported higher quality of life compared with the control group.69
INTERACT tools
Led by Dr. Joseph Ouslander, INTERACT (Interventions to Reduce Acute Care Transfers)70 is a quality-improvement initiative for skilled nursing facilities, designed to facilitate the early identification, evaluation, documentation, and communication of changes in the status of residents. Visitors to its website can download a set of tools and strategies to help them manage conditions before they become serious enough to require a hospital transfer. The tools assist in promoting important communication among providers and enhancing advance-care planning.
A 6-month study in 25 nursing homes showed a 17% reduction in self-reported hospital admissions with this program compared with the same period the previous year.71
Additional home-based care interventions
Additional innovations are under way in home-based care.
The Home Health Quality Improvement National Campaign is a patient-centered movement to improve the quality of care received by patients residing at home.72 Through its Best Practices Intervention Packages, it offers evidence-based educational tools, resources, and interventions for reducing avoidable hospitalizations, improving medication management, and coordinating transitional care.
The Center for Medicare and Medicaid Innovation Independence at Home Demonstration73 is testing whether home-based comprehensive primary care can improve care and reduce hospitalizations for Medicare beneficiaries with multiple chronic conditions.
