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

Setting

Cedars-Sinai Medical Center (CSMC) is an 850-bed, acute care facility located in an urban area of Los Angeles. Eight SNFs, ranging in size from 49 to 150 beds and located between 0.6 and 2.2 miles from CSMC, were invited to partner with the ECP. The physician community encompasses more than 2000 physicians on the medical staff, including private practitioners, nonteaching hospitalists, full-time faculty hospitalists, and faculty specialists.

Study Design and Patients

This was an observational, retrospective cohort analysis of 30-day same-hospital readmissions among 3951 patients discharged from CSMC to 8 SNFs between January 1, 2014, and June 30, 2015. A total of 2394 patients were enrolled in the ECP, and 1557 patients were not enrolled.

ECP Enrollment Protocol

Every patient discharged from CSMC to 1 of the 8 partner SNFs was eligible to participate in the program. To respect the autonomy of the SNF attending physicians and to facilitate a collaborative relationship, the decision to enroll a patient in the ECP rested with the SNF attending physician. The ECP team maintained a database that tracked whether each SNF attending physician (1) opted to automatically enroll all his or her patients in the ECP, (2) opted to enroll patients on a case-by-case basis (in which case an ECP nurse practitioner [NP] contacted the attending physician for each eligible patient), or (3) opted out of the ECP completely. When a new SNF attending physician was encountered, the ECP medical director called the physician to explain the ECP and offer enrollment of his or her patient(s). Ultimately, patients (or their decision-makers) retained the right to opt in or out of the ECP at any time, regardless of the decision of the attending physicians.

Program Description

Patients enrolled in the ECP experienced the standard care provided by the SNF staff and attending physicians plus a clinical care program delivered by 9 full-time NPs, 1 full-time pharmacist, 1 pharmacy technician, 1 full-time nurse educator, a program administrator, and a medical director.

The program included the following 3 major components:

1. Direct patient care and 24/7 NP availability: Program enrollment began with an on-site, bedside evaluation by an ECP NP at the SNF within 24 hours of arrival and continued with weekly NP rounding (or more frequently, if clinically indicated) on the patient. Each encounter included a review of the medical record; a dialogue with the patient’s SNF attending physician to formulate treatment plans and place orders; discussions with nurses, family members, and other caregivers; and documentation in the medical record. The ECP team was on-site at the SNFs 7 days a week and on call 24/7 to address questions and concerns. Patients remained enrolled in the ECP from SNF admission to discharge even if their stay extended beyond 30 days.

2. Medication reconciliation: The ECP pharmacy team completed a review of a patient’s SNF medication administration record (MAR) within 72 hours of SNF admission. This process involved the pharmacy technician gathering medication lists from the SNFs and CSMC and providing this information to the pharmacist for a medication reconciliation and clinical evaluation. Discrepancies and pharmacist recommendations were communicated to the ECP NPs, and all identified issues were resolved.

3. Educational in-services: Building upon the INTERACT II model, the ECP team identified high-yield, clinically relevant topics, which the ECP nurse educator turned into monthly educational sessions for the SNF nursing staff at each of the participating SNFs.¹⁰

Primary Outcome Measure

An inpatient readmission to CSMC within 30 days of the hospital discharge date was counted as a readmission, whether the patient returned directly from an SNF or was readmitted from home after an SNF discharge.

Data

ECP patients were identified using a log maintained by the ECP program manager. Non-ECP patients discharged to the same SNFs during the study period were identified from CSMC’s electronic registry of SNF discharges. Covariates known to be associated with increased risk of 30-day readmission were obtained from CSMC’s electronic data warehouse, including demographic information, length of stay (LOS) of index hospitalization, and payer.¹² Eleven clinical service lines represented patients’ clinical conditions based on Medicare-Severity Diagnosis-Related groupings. The discharge severity of illness score was calculated using 3M All Patients Refined Diagnosis Related Group software, version 33.¹³

Analysis

Characteristics of the ECP and non-ECP patients were compared using the χ² test. A multivariable logistic regression model with fixed effects for SNF was created to determine the program’s impact on 30-day hospital readmission, adjusting for patient characteristics. The Pearson χ² goodness-of-fit test and the link test for model specification were used to evaluate model specification. The sensitivity of the results to differences in patient characteristics was assessed in 2 ways. First, the ECP and non-ECP populations were stratified based on race and/or ethnicity and payer, and the multivariable regression model was run within the strata associated with the highest readmission rates. Second, a propensity analysis using inverse probability of treatment weighting (IPTW) was performed to control for group differences. Results of all comparisons were considered statistically significant when P < 0.05. Stata version 13 was used to perform the main analyses.¹⁴ The propensity analysis was conducted using R version 3.2.3. The CSMC Institutional Review Board (IRB) determined that this study qualified as a quality-improvement activity and did not require IRB approval or exemption.