Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle

Abstract

Care coordination has shown inconsistent results as a mechanism to reduce hospital readmission and postdischarge emergency department (ED) visit rates. OBJECTIVE:To assess the impact of a supplemental care bundle targeting high-risk elderly inpatients implemented by hospital-based staff compared to usual care on a composite outcome of hospital readmission and/or ED visitation at 30 and 60 days following discharge. PATIENTS/METHODS:Randomized controlled pilot study in 41 medical inpatients predisposed to unplanned readmission or postdischarge ED visitation, conducted at Baylor University Medical Center. The intervention group care bundle consisted of medication counseling/reconciliation by a clinical pharmacist (CP), condition specific education/enhanced discharge planning by a care coordinator (CC), and phone follow-up. RESULTS:Groups had similar baseline characteristics. Intervention group readmission/ED visit rates were reduced at 30 days compared to the control group (10.0% versus 38.1%, P ¼ 0.04), but not at 60 days (30.0% versus 42.9%, P ¼ 0.52). For those patients who had a readmission/postdischarge ED visit, the time interval to this event was longer in the intervention group compared to usual care (36.2 versus 15.7 days, P ¼ 0.05). Study power was insufficient to reliably compare the effects of the intervention on lengths of index hospital stay between groups. KEYWORDS: care coordination, discharge planning, elderly care, hospital readmission, transitional care. CONCLUSIONS:Elderly patients (aged 65 years and older) consume a disproportionate amount of acute health care resources, composing up to 20% of emergency department (ED) visits, 1,2 having a 2-fold to 5-fold increase in likelihood of hospital admission, 1 and frequently incurring lengths of hospital stay (LOS) approximately 15% higher than the national averages. 3 In addition, they are at increased risk for hospital readmission in the 90-day interval following hospital discharge. 1,4,5 Specific risk factors for readmission include age above 80 years, discharge within the previous 30 days, the presence of 3 or more comorbid diagnoses, use of 5 or more prescription medications, difficulty with at least 1 activity of daily living (ADL), and lack of discharge education. 6 These risk factors can translate into adverse drug events, 7-9 exacerbations of chronic diseases, 10 or functional decline 4,5 that can trigger ED visits or hospital readmission.Hospital-based care coordination-defined as a multidisciplinary interaction between inpatients and providers that focuses on education, communication, and discharge planning with the primary aim of improving outcomes-has demonstrated inconsistent results as a mechanism to reduce LOS, postdischarge ED visits, or hospital readmission rates. While disease-specific care coordination programs for congestive heart failure and chronic obstructive pulmonary disease have been effective in reducing rehospitalization rates, 10-15 the benefits of comprehensive care coordination for elderly general medical inpatients wit...

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