Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment
BACKGROUND: Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.
OBJECTIVE: To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions.
DESIGN: Retrospective cohort.
PATIENTS: A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013.
SETTING: Midwest primary care practice in an integrated health system.
INTERVENTION: Enrollment in a CTP during acute hospitalization.
MEASUREMENTS: The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare.
RESULTS: The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission.
CONCLUSIONS: No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.
© 2019 Society of Hospital Medicine
Unplanned hospital admissions and readmissions have become a major focus of efforts to improve the value of healthcare given that these potentially preventable events exert substantial burden on patients, caregivers, health systems, and the economy.1 The percentage of patients who are rehospitalized within 30 days have decreased from 20%-21% at the start of the Accountable Care Act and readmission penalties to approximately 18%.2-5 Rehospitalization rates are 33% at 90 days and approach 40% at six months.6,7 Readmissions cost Medicare more than $26 billion annually,4 with one in five Medicare beneficiaries readmitted within 30 days of hospital discharge.8 Centers for Medicare and Medicaid Services and other payers use condition-specific and all-cause 30-day unplanned readmission rates and potentially preventable admissions among patients with complex or multiple comorbidities for public reporting, value-based purchasing, and performance-based reimbursement.9,10 Consequently, medical groups and hospitals have begun to place an increasing emphasis on improving the transitions of care following hospitalization with the goal of reducing unplanned readmissions.11 Care transitions programs have been shown to decrease readmission rates, mortality, and emergency department (ED) visits.12
Care transitions programs vary greatly in their scope of intervention and target groups, as well as in their efficacy in reducing readmissions.13,14 The Mayo Clinic Care Transition Program, hereafter referred to as CTP, was launched in 2011. This program was modeled after other successful programs and involves home visits by a nurse practitioner (NP) and telephonic support and triage provided by a registered nurse (RN). It is offered to high-risk community-dwelling patients during their hospitalization and begins within a week of hospital discharge.
Although the CTP reduces 30-day readmissions from 20% to 17%,7 it is a highly resource-intensive, multimodal, multidisciplinary program. Moreover, whether some components of the CTP are more critical than others remains unknown. Prior studies that examined the individual components of successful CTPs have suggested that a multipronged approach that includes close patient and caregiver support is most predictive of program efficacy.13 Long-term program sustainability would benefit from optimization of the most critical components of the program while reducing or eliminating resource-intensive factors that have negligible effects on program success. We therefore examined our CTP to identify whether and which program components are most critical for preventing 30-day readmissions and whether any patient characteristics contribute risk within this complex population.
