Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness

Abstract

BACKGROUND: People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. OBJECTIVE: To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. DESIGN: This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. PARTICIPANTS: Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. MAIN MEASURES: Unplanned all-cause readmission to the study hospital within 90 days of discharge. KEY RESULTS: Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). CONCLUSION: Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.

Acute injection‐related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management

“…In our cohort, unstable housing was associated with unplanned discharge. This is consistent with other studies, and highlights the vulnerability of this cohort, who may have competing demands and unique needs to support an inpatient stay [ 37 ]. Further opportunistic care may be directed at comorbid psychiatric conditions and cigarette smoking, which were both highly prevalent in this cohort.…”

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial

“…This intervention was informed by a recent prospective cohort study conducted at the urban academic teaching hospital, which found that having an active case manager, sending discharge summaries to PCPs, and informal support were associated with reduced readmissions among homeless adults. 22 The first HOC position was created in February 2019 and has since been expanded to two positions and adapted through conversations with community partners and hospital staff. Ultimately, the goal of the Navigator Programme is to help homeless patients who are discharged from the hospital overcome systemic barriers and discontinuities in care that often result in poor health and high acute care utilisation.…”

“…Indeed, there is abundant evidence suggesting that homeless adults rely heavily on acute care services, and rates of ED visits and hospitalisations are much higher among homeless versus non-homeless adults 18–21. A related problem is the high rate of hospital readmissions among homeless adults 18 19 22 23. Many of these readmissions are thought to be potentially preventable with more complete treatment and better coordination of health and social services following hospital discharge 24 25.…”

“…The Navigator Programme features Homeless Outreach Counsellors (HOCs)—whose roles are to create strong links between community services and patients through regular contact, supporting patients in following their postdischarge care plans, and helping patients in meeting their health-related and social-related competing priorities. This intervention was informed by a recent prospective cohort study conducted at the urban academic teaching hospital, which found that having an active case manager, sending discharge summaries to PCPs, and informal support were associated with reduced readmissions among homeless adults 22. The first HOC position was created in February 2019 and has since been expanded to two positions and adapted through conversations with community partners and hospital staff.…”

Readmission rates and predictors of avoidable readmissions in older adults in a tertiary care centre

“…[ 4 ] Factors associated with readmission include improper discharge planning; failure to send the discharge plan to the primary care physician; poor follow-up practices, especially with primary care physicians; lack of social and community support; unclear instructions to patients on discharge; incomplete diagnosis; inadequately treated medical conditions; sub-optimal patient care; errors in medication reconciliation; drug interactions and side effects; frailty; malnutrition; severe chronic conditions; the persistence of underlying chronic conditions; lapses in communication between treating team members and the patient; poor management of self-care activities at home following discharge; inability in accessing health care and keeping appointments; incomplete patient education resulting in lack of awareness of whom to contact; where to go and how to manage symptoms at home; nosocomial infections; and poor adherence to medications due to cost or inaccessibility. [ 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 ] Contributory intrinsic factors include old age, high comorbidity burden, low literacy rate, low socio-economic status, and lack of social networks. [ 9 10 22 23 24 ] Patients discharged against medical advice are at a higher risk for early readmissions, usually within the first day following discharge (bounce-back readmissions).…”