Factors Associated With 30-Day Hospital Readmissions Among Participants in a Care Transition Quality Improvement Program

Abstract

Discharge from hospital to home is a vulnerable period for older adults who have multiple care needs. The Safe Transitions for Elderly People (STEP) program is a care transition program for Medicare fee-for-service patients 75 years and older discharged to home from a community hospital. This quality improvement project (a) compares 30-day hospital readmission rates between 498 STEP participants and 722 patients eligible for STEP but not participating in the program, and (b) determines factors associated with readmissions during STEP. The STEP participants received intervention in 1 of 2 formats: 395 received a telephone-only intervention and 103 received a telephone plus home visit intervention. STEP participants had a lower 30-day hospital readmission rate than nonparticipants (i.e., those who could not be contacted for STEP participation; those who declined to participate). Results of binary logistic regressions showed 2 variables were significant predictors of readmissions: for the group of all STEP participants and the telephone-only intervention group, the (a) hospitalization within the previous year predicted readmission; for the telephone plus home visit group, the (b) degree of assistance needed with ambulation predicted readmission. Given the multifactor nature of readmissions, interdisciplinary teams should develop tailored interventions based on individual's psychosocial and medical assessments. Reforms to the Medicare fee-for-service system have the potential to change financial incentives that currently favor hospitalization of older patients, the potential to avoid readmissions, and the potential to direct the savings to support interdisciplinary care transition interventions.

Health Promotion Practices in Nursing for Elderly Persons in Municipal Home Care: An Integrative Literature Review

“…25 At the same time, investments in health promotion are more efficient for the national economy than curative and rehabilitative services. 33 Health promotion in primary care reduces the number of hospitalizations, 34 and our study show the same effect among home care patients.…”

“…In addition, making the plan gives the nurse a chance to educate the patient, which is an important aspect in facilitating behavioral changes and ensuring that appropriate health services are used. [24][25][26][27]29,31,33,34 Health promotion is strengthened through multi-professional teams working together, 34 and cooperation among caregivers has been highlighted by World Health Organization (WHO) 15 as an important part of health promotion work and for avoiding visits to emergency care clinics. 35 For health promotion work, it is important that the RN collaborates with other professionals because home care cannot by itself take full responsibility for health promotion.…”

Who is High Risk Elderly Patient?

“…After patients were discharged from hospital, they were followed up by phone, and clinical assessments were performed with the help of an educated home care nurse in the houses of individuals who had given consent. While the rate of re-hospitalization was found to be lower in patients visited at their homes, it was higher in patients who had not given consent and those who could not be contacted (40). Moreover, the results indicate that rehospitalization is associated with previous re-hospitalization, low social support, depression, poor drug compliance, and late visit from the family physician (41,42).…”

“…The STEP (Safe Transitions for Elderly People) program is a project in which 1220 patients older than 75 years were evaluated and attempts were made to identify the characteristics related to re-hospitalizations within 30 days (40). This program was designed as a basic care intervention plan.…”

Digital Predictors of Morbidity, Hospitalization, and Mortality Among Older Adults: A Systematic Review and Meta-Analysis

“…A full description of the included studies is depicted in Tables 2A , 2B . Two of the included studies were RCTs ( 41 , 46 ), 28 prospective ( 10 , 13 – 20 , 30 , 31 , 34 – 40 , 43 – 45 , 47 , 48 , 50 , 53 , 58 – 60 ) and 13 retrospective cohort studies ( 12 , 21 , 29 , 32 , 33 , 42 , 49 , 51 , 52 , 54 – 57 ). The total number of older participants (≥65 years) included in the analysis was 92,994, of whom, 48% ( n = 44,461) were males and 52% ( n = 48,533) females.…”