Two interventions to improve the transition from hospital discharge to home care, and to thereby reduce readmissions, were effective in the first attempts to implement them in real-world settings, according to separate reports in the July 25 issue of Archives of Internal Medicine.
Both interventions had been effective in the comparatively controlled conditions of several randomized controlled trials, but until now it wasn’t known whether that success would translate into real-world practice.
In the first report, a Medicare demonstration project following the Care Transitions Intervention (CTI) model was assessed in 257 adults in the Medicare fee-for-service program who were hospitalized for a variety of diagnoses at six Rhode Island medical centers during an 18-month period. The facilities included community hospitals, teaching hospitals, and a tertiary care center, and their size ranged from 129 to 719 beds, said Rachel Voss of Quality Partners of Rhode Island, the Medicare Quality Improvement Organization for Rhode Island, and her associates.
The CTI is a 1-month program designed to help patients on the verge of discharge and their families to manage their health more actively and to communicate more effectively with their providers. Nurses or social workers act as "coaches" who conduct a hospital visit, a home visit within 3 days of discharge, a phone visit within 7-10 days, and a final phone visit within 30 days.
At these visits, the coaches review a booklet in which patients record their health problems, medications, and questions for providers; troubleshoot problems with outpatient care; ensure patients understand the signs and symptoms of worsening of their condition before an emergency issue develops; and help patients locate other sources of continued support.
Before implementation of the CTI program, the average 30-day readmission rate at the six participating hospitals was 21%. In comparison, the rate was only 12.8% in patients who participated in the intervention.
The primary outcome measure of the study was the difference between the readmission rate among the study participants (12.8%) and a control group of similar patients who did not participate (20%). This represents a 36% reduction in readmissions with the intervention program, a significant decrease, Ms. Voss and her colleagues said (Arch. Intern. Med. 2011;171:1232-7).
One drawback revealed in this study was the lack of success in recruiting and retaining study patients willing to participate in the intervention. Only 55% of the patients who were approached agreed to participate, and the attrition rate among those who initially agreed to a home visit was 75%, the researchers noted.
The second report was a pilot study at a single medical center involving patients with heart failure, a disorder for which hospital readmission is particularly common. The 3-month intervention was a traditional care program (TCP) in which advanced practice nurses educated patients and families about symptoms and self-management strategies, improved communication patterns with care providers, and marshaled caregiver and community resources to facilitate adherence to treatment and improve quality of life.
It included at least eight home visits, beginning within 72 hours of hospital admission, as well as 24-hour phone availability.
A total of 140 Medicare fee-for-service patients with heart failure were eligible, and 56 enrolled in the study. Once again only 40% of eligible patients agreed to participate in the intervention, said Dr. Brett D. Stauffer of the Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, and his associates.
The 30-day readmission rate was 48% lower after the intervention was implemented than it had been before. No such reduction in readmissions was noted at other medical centers in the same area during the study period, Dr. Stauffer and his colleagues said.
Total direct costs were lower for patients who participated in the intervention than for those who did not; however, the cost of the intervention itself was not recovered by the hospital.
The hospital actually lost revenue by preventing readmissions, because under the current payment system, readmissions are fully reimbursed. If and when this payment system is revised as part of health care reform, both the individual patients and the hospital itself will save money in their efforts to keep patients healthy and out of the hospital, the investigators said.
Ms. Voss’s study was funded by the Centers for Medicare and Medicaid Services. Dr. Stauffer’s study was supported by the Baylor Health Care System, Dallas. Both research groups reported no financial conflicts of interest.