The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality

Kamermayer, Angela K.; Leasure, A. Renee; Anderson, Lisa

doi:10.1097/dcc.0000000000000266

Cited by 39 publications

(47 citation statements)

References 16 publications

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“…28 Efforts to improve the hospital-SNF transition should attempt to include the patient and family member, consistent with how similar efforts address the hospital-home transition. [11][12][13] Ideally, these efforts to include patients and family members should begin with post-acute setting selection, since research suggests that patients may prioritize aspects of their own care experience over standardized quality measures. 29 Our study indicates that patients and family members would like to be involved in the PAC transition process; indeed, they described not being included as Ba missed setup,^and expressed confusion about their own medications, not knowing about appointments, that they did not know what to ask hospital and SNF staff, and that they Bwould have enjoyed knowing a little bit more.F uture research might directly focus on the development and implications of programs aimed to address PAC continuity issues found by the present research.…”

Section: Discussionmentioning

confidence: 99%

“…Unlike efforts to improve transitions from hospitals to SNFs, these interventions often actively include patients and their families. [11][12][13] Such interventions commonly use the Coleman Care Transitions Program, 14 the Transitional Care Model, 15 or ProjectRED (Re-Engineered Discharge), 16 and might include helping patients and caregivers identify their own goals, home visits, or follow-up calls with patients post-discharge, or the use of transition coaches who train patients and their families on PAC skills. The lack of such patient-focused initiatives in the transition from hospital to SNF may be due in part to their complexity: whereas hospital-home initiatives are able to directly engage patients in both the hospital and home, hospital-SNF initiatives would require engaging multiple institutions: hospitals and SNFs.…”

Section: Introductionmentioning

confidence: 99%

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Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

et al. 2018

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OBJECTIVE: This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff. DESIGN: We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process. PARTICIPANTS: Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets. APPROACH: Interviews were qualitatively analyzed to identify overarching themes. KEY RESULTS: Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown. CONCLUSIONS: Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

et al. 2018

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“…On average, studies included three (range: 1-12) scheduled home visits and two (range: 1-13) scheduled telephone follow-up calls. Kamermeyer 12 Studies utilised multicomponent discharge interventions, including standardised discharge instructions, a post-discharge provider appointment, follow-up phone calls and medication reconciliation.…”

Section: Studymentioning

confidence: 99%

Reducing unplanned admission to hospital of community dwelling adults: evidence review

MacGillivray¹,

Gray²

2019

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“…However, the effectiveness of TCPs in reducing readmission and mortality has so far provided mixed results. Most programs demonstrated an improvement in patient outcomes, but a substantial number showed limited impact or worse outcomes (11)(12)(13)(14)(15). A possible explanation for such inconsistency may be due to different patient subgroups with accompanying risk profiles presenting with varying responses to a standardized TCP intervention.…”

Section: Introductionmentioning

confidence: 99%

The heterogeneous health state profiles of high-risk healthcare utilizers and their longitudinal hospital readmission and mortality patterns

Kwan

Shi

et al. 2019

Preprint

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Background: High-risk patients are most vulnerable during transitions of care. Due to the high burden of resource allocation for such patients, we propose that segmentation of this heterogeneous population into distinct subgroups will enable improved healthcare resource planning. In this study, we segmented a high-risk population with the aim to identify and characterize a patient subgroup with the highest 30-day and 90-day hospital readmission and mortality. Methods: We extracted data from our transitional care program (TCP), a Hospital-to-Home program launched by the Singapore Ministry of Health, from June to November 2018. Latent class analysis (LCA) was used to determine the optimal number and characteristics of latent subgroups, assessed based on model fit and clinical interpretability. Regression analysis was performed to assess the association of class membership on 30- and 90-day all-cause readmission and mortality. Results: Among 752 patients, a 3-class best fit model was selected: Class 1 “Frail, cognitively impaired and physically dependent”, Class 2 “Pre-frail, but largely physically independent” and Class 3 “Physically independent”. The 3 classes have distinct demographics, medical and socioeconomic characteristics (p<0.05), 30- and 90-day readmission (p<0.05) and mortality (p<0.01). Class 1 patients have the highest age-adjusted 90-day readmission (OR=2.04, 95%CI: 1.21-3.46, p= 0.008), 30- (OR=6.92, 95%CI: 1.76-27.21, p=0.006) and 90-day mortality (OR=11.51, 95%CI: 4.57-29.02, p<0.001). Conclusions: We identified a subgroup with the highest readmission and mortality risk amongst high-risk patients. We also found a lack of interventions in our TCP that specifically addresses increased frailty and poor cognition, which are prominent features in this subgroup. These findings will help to inform future program modifications and strengthen existing transitional healthcare structures currently utilized in this patient cohort.

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The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality

Abstract: The findings of this review support the use of transitions-of-care interventions such as tailored discharge planning and postdischarge phone calls.

Cited by 39 publications

References 16 publications

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

Reducing unplanned admission to hospital of community dwelling adults: evidence review

The heterogeneous health state profiles of high-risk healthcare utilizers and their longitudinal hospital readmission and mortality patterns

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