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

RESULTS

The average unadjusted 30-day readmission rate for ECP patients over the 18-month study period was 17.2%, compared to 23.0% for patients not enrolled in ECP (P < 0.001) (Figure 1). After adjusting for patient characteristics, ECP patients had 29% lower odds (95% confidence interval [CI], 0.60-0.85) of being readmitted to the medical center within 30 days than non-ECP patients at the same SNFs. The characteristics of the ECP and comparison patient cohorts are shown in Table 1. There were significant differences in sociodemographic characteristics: The ECP group had a higher proportion of non-Hispanic white patients, while the comparison group had a higher proportion of patients who were African American or Hispanic. ECP patients were more likely to prefer speaking English, while Russian, Farsi, and Spanish were preferred more frequently in the comparison group. There were also differences in payer mix, with the ECP group including proportionately more Medicare fee-for-service (52.9% vs 35.0%, P < 0.001), while the comparison group had a correspondingly larger proportion of dual-eligible (Medicare and Medicaid) patients (55.0% vs 35.1%, P < 0.001).

The largest clinical service line, orthopedic surgery, had the lowest readmission rate. The highest readmission rates were found among patients with medical cardiology hospitalizations, pulmonary diseases, and gastroenterology conditions. There was a significant monotonic relationship between quartiles of index hospital LOS and 30-day readmission (Supplemental Table 1).

The largest clinical differences observed between the ECP and non-ECP groups were the proportions of patients in the clinical service lines of orthopedic surgery (28.7% vs 21.1%, P < 0.001), medical cardiology (7.4% vs 9.7%, P < 0.001), and surgery other than general surgery (5.8% vs 9.2%, P < 0.001). Despite these differences in case mix, no differences were seen between the 2 groups in discharge severity of illness or LOS of the index hospitalization. The distribution of index hospital LOS by quartile was the same, with the exception that the ECP group had a higher proportion of patients with longer LOS.

Results of the multivariable logistic regression analysis are shown in Table 2. Males had 27% higher odds of readmission (95% CI, 1.07-1.50), and patients who were dually eligible for Medicare and Medi-Cal (California’s Medicaid program) had 37% higher odds of readmission (95% CI, 1.10-1.69). Compared with patients who had orthopedic surgery, the clinical service lines with significantly higher rates of readmission were gastroenterology (odds ratio [OR] 1.91; 95% CI, 1.33-2.73), medical cardiology (OR 1.89; 95% CI, 1.35-2.65), and pulmonary (OR 1.66; 95% CI, 1.16-2.37). Severity of illness at discharge and index hospital LOS were both positively associated with readmission in the adjusted analysis.

Sensitivity Analyses

The results were robust when tested within strata of the study population, including analyses limited to dual-eligible patients, African American patients, patients admitted to all except the highest volume facility, and patients admitted to any service line other than orthopedic surgery. Similar results were obtained when the study population was restricted to patients living within the medical center’s primary service area and to patients living in zip codes in which the proportion of adults living in households with income below 100% of the poverty level was 15% or greater (see Supplementary Material for results).

The effect of the program on readmission was also consistent when the full logistic regression model was run with IPTW using the propensity score. The evaluation of standardized cluster differences between the ECP and non-ECP groups before and after IPTW showed that the differences were reduced to <10% for being African American; speaking Russian or Farsi; having dual-eligible insurance coverage; having orthopedic surgery; being discharged from the clinical service lines of gastroenterology, pulmonary, other surgery, and other services; and having an index hospital LOS of 4 to 5 days or 10 or more days (results are provided in the Supplementary Material).

Figure 2 displays the 30-day readmission rate for all Cedars-Sinai patients discharged to any SNF in the 3 years preceding and 4 years following the intervention. The readmission rate in the 12-month period immediately prior to the launch of the ECP was 19.6%. That rate dropped significantly to 17.5% in the first 12-month period postimplementation (P = 0.016) and to 16.6% in the next 12 months (P > 0.001 for the overall decline). During the study period, 66% of all Cedars-Sinai patients who were discharged to a SNF were admitted to 1 of the 8 participating SNFs. More than half of those patients (representing approximately 40% of all CSMC SNF discharges) were enrolled in the ECP.

DISCUSSION

Hospitals continue to experience significant pressure to manage LOS, and SNFs and hospitals are being held accountable for readmission rates. The setting of this study is representative of many large, urban hospitals in the United States whose communities include a heterogeneous mix of hospitalists, primary care physicians who follow their patients in SNFs, and independent SNFs.¹⁵ The current regulations have not kept up with the increasing acuity and complexity of SNF patients. Specifically, Medicare guidelines allow the SNF attending physician up to 72 hours to complete a history and physical (or 7 days if he or she was the hospital attending physician for the index hospitalization) and only require monthly follow-up visits. It is the opinion of the ECP designers that these relatively lax requirements present unnecessary risk for vulnerable patients. While the INTERACT II model was focused largely on educational initiatives (with an advanced practice nurse available in a consultative role, as needed), the central tenet of ECP was similar to the Connected Care model in that the focus was on adding an extra layer of direct clinical support. Protocols that provided timely initial assessments by an NP (within 24 hours), weekly NP rounding (at a minimum), and 24/7 on-call availability all contributed to helping patients stay on track. Although the ECP had patients visited less frequently than the Connected Care model, and the Cleveland Clinic started with a higher baseline 30-day readmission rate from SNFs, similar overall reductions in 30-day readmissions were observed. The key point from both initiatives is that an increase in clinical touchpoints and ease of access to clinicians generates myriad opportunities to identify and address small issues before they become clinical emergencies requiring hospital transfers and readmissions.