Acute care hospitalizations have consistently accounted for the largest portion of total Medicare expenditures hovering around 27% over the last few years [1–4]. In a recent study, Jencks et al. [5] found that one in five acute care hospitalizations in the United States result in readmission within 30 days which stimulated national discussion on poor quality care as a root cause. The Centers for Medicare and Medicare Services (CMS) began publicly reporting hospitals’ 30-day readmission rates for Medicare beneficiaries discharged for congestive heart failure, acute myocardial infarction, and pneumonia [6]. The Medicare Payment Advisory Commission (MedPAC) estimated that the costs associated with 30-day hospital readmissions accounted for approximately $15 billion in annual Medicare spending, with the majority of those costs attributable to preventable causes [7]. Medicare’s Hospital Readmission Reduction Program, resulting from the 2010 Affordable Care Act, proposed penalties for those hospitals with excessively high readmission rates for heart attack, heart failure, and pneumonia [8]. With a proposed maximum penalty equal to 1% of regular Medicare reimbursements, this law stimulated change in how hospitals regard 30-day readmissions and they examined factors that contributed to them. Hospitals began to identify phenomena that contributed to a post-discharge period of vulnerability. Shorter hospital stays and an increased acuity of illness paired with higher expectations for self-care, low health literacy, and cognitive impairments adds to the vulnerability associated with being discharged from an acute care facility [9]; while receiving quality care during the initial hospitalization, effective discharge planning, coordinated post-hospital care, and timely follow-up can prevent readmission [10]. The problem of 30-day readmissions is worldwide, however. In one study comparing international readmission for acute myocardial infarctions, the 30-day readmission rate was 7.7% in non-U.S. countries including Canada, Australia, New Zealand, and 13 European countries [11]. Another study examining international hospital readmissions found that shorter stays correlated with higher readmission rates and vice versa [12]. Explanations can be sought in differences among healthcare systems and policies.
Needing to improve the current state of post-discharge care, researchers explored effective delivery models to assist in these transitions of care from the hospital to home addressing the gaps in care that occur. Several studies in transitional care have shown that properly designed and executed programs improve quality outcomes and achieve cost savings [13–15]. The Community-Based Care Transitions Program (CCTP), created by the Affordable Care Act, began supporting research designed to test transitional care models to reduce readmissions for beneficiaries and document savings to the Medicare program [16]. Acting as a community liaison, community-based organizations (CBOs) can reduce fragmentation, improve collaboration and coordinate care across settings, and offer additional resources to an expanding aging population with multiple chronic conditions [17]. A community-based organization is a “public or private nonprofit (including a church or religious entity) that is representative of a community or a significant segment of a community, and is engaged in meeting human, educational, environmental, or public safety community needs” [18]. Care coordination involves the sending healthcare team, the receiving healthcare team, and the administrative leadership of the healthcare institution [19]. The USDHHS [17] identified several elements that promote safe and effective care transitions including:
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Patient and/or caregiver training to increase activation and self-care skills.
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Patient-centered care plans that are shared across settings of care.
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Standardized, accurate, and timely communication and information exchange between the transferring and receiving healthcare teams.
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Medication reconciliation and safe medication practices.
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Ensured transportation for health care-related travel.
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Procurement and timely delivery of durable medical equipment.
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Ensuring the sending healthcare team maintains responsibility for care of the patient until the receiving healthcare team confirms the transfer and assumes responsibility (¶12).
Identified proxies for inadequate care transitions include medication errors, increased health care utilization, redundancies in care, inadequate patient and/or staff preparation, family and/or caregiver stress, inadequate follow-up care, litigation, and dissatisfaction [19]. Aspects of care that are critical to a successful care transition include information transfer, a plan to target at-risk patients, reimbursement incentives aligned with transitional care, new models of care delivery, and best practices for transitional care [18]. Here, we describe an Arizona CBO’s care transition program, present program evaluation findings, and discuss the implications and lessons learned from this experience.
System description
Sun Health, an Arizona CBO, has longstanding relationships with nearby healthcare institutions and provides community support programs including senior living services, philanthropic support, medication management, community education, and other programs to support healthy senior living. In November 2011, Sun Health launched a care transitions program in collaboration with two area hospitals. The two hospitals belong to a larger nonprofit health system that Sun Health is neither operationally nor financially related to, but whom approached Sun Health as a community partner. Before developing and implementing a care transitions program, the scope of the problem was defined using the STate Action on Avoidable Rehospitalizations Readmission (STAAR) Diagnostic Review tool [20] as part of a system-wide assessment. The qualitative and quantitative root cause analysis included chart reviews and interviews with patients, caregivers, and providers across care settings who were involved in the circumstances leading up to readmission. Key findings of the diagnostic review are presented here. Additional research performed at both hospitals revealed no clear pattern of readmissions based on discharge or admission day of the week, attending physician or PCP.
In 2010, Hospital A had 6,478 Medicare FFS readmissions among 4,732 individual patients. The all-cause unadjusted 30-day readmission rate was 14.7% (908/6148). Fifty percent (470) of the 30-day readmissions occurred within 10 days of discharge; 15% of those (131) occurred within 48 hours; 20% (178) occurred within 72 hours; and 25% (235) occurred within 4 days of discharge. Fourteen diagnoses accounted for 25% (242/908) of readmissions. The top primary diagnoses by volume included heart failure, renal failure, urinary tract infection, gastrointestinal bleeding, anemia, sepsis, arrhythmia, chest pain, gastritis, esophagitis, syncope, pneumonia, respiratory infection, and chronic obstructive pulmonary disease.
In the same year, Hospital B had 8,586 Medicare FFS admissions among 6,064 individual patients. The all-cause unadjusted 30-day readmission rate was 15.4% (1276/8298). Fifty percent (588) of the 30-day readmissions occurred within 10 days of discharge and 25% (294) occurred within 4 days of discharge. The same fourteen diagnoses accounted for a similar percentage of readmissions with the addition of stent placement (29/188) relative to the expertise of Hospital B. Additional evaluation of both hospitals revealed no clear pattern of readmissions based on discharge or admission day of the week, attending physician, or primary care provider.
Chart reviews were completed on ten patients from Hospital A and B, for a total of 20. Family and provider interviews were conducted on the same 20 readmissions. The following four themes were observed from those interviews: (1) lack of availability of physician follow up visits within seven (7) days of discharge; (2) late discharges contributing to patient fatigue, hindering comprehension of discharge instructions and ability to get prescriptions filled; (3) medication issues (prescriptions not filled, incomplete patient instructions, duplicate therapies prescribed, non-adherence); and (4) vague discharge instructions and/or patient education materials. Patients reported feeling overwhelmed with new information, were uncertain about next steps in the plan of care, and needed additional support in the post-discharge period.
Based upon program results from the CTI [13] and consistent with the Partnership for Patients [21], the initial goal of the Sun Health care transitions program was to reduce the expected readmission rate of 19.7% among a population of 1,800 patients by 20%, which would prevent 72 readmissions annually. Using the Medicare FFS data provided on the Institute of Medicine Hospital Referral Region (HRR) [22] the average cost of a Medicare hospitalization in the identified service area is $13,387; thus, this program aims to avoid $963,789 in annual costs attributed to avoided hospitalizations for those 72 patients. The blended rate (including in-hospital and program nurses’ time, mileage, supervision, and materials) for the Sun Health care transitions program administration services was estimated at $360 per discharge. The total cost of the Sun Health care transitions program is $648,000 for 1,800 patients; thus, this program potentially offers CMS a net savings of −30% or $288,864 (difference between annual cost savings and cost to administer the program).
Along with this diagnostic review, the literature on care transition interventions was reviewed and used to develop a customized program to adequately service the study population using existing institutional-based interventions for at-risk Medicare fee-for-service (FFS) beneficiaries discharged to home without skilled home care services. The Sun Health care transitions program was modeled after the Coleman Transition Intervention (CTI) [13], Naylor’s Transitional Care Model (TCM) [14, 15], and other national recommendations describing essential components of safe and effective care transitions [17, 19]. The Sun Health care transitions program targeted the three diagnoses indicated by the Hospitals Readmissions Reductions Program [16] and then expanded to other diagnoses based on the diagnostic review conducted by the CBO. Because an all-RN model was cost-prohibitive, the Sun Health care transitions program employed licensed practical nurses (LPNs) to enroll patients and coordinate care, and employed registered nurses (RNs) to make home visits. Program nurses worked with both hospitals’ nurse case managers (CMs) to identify potential program enrollees. The aims of the care transitions program were to (1) educate patients about their health condition, including red flags, and teach self-monitoring of chronic disease; (2) perform a medication reconciliation and create an up to date medication list; (3) ensure timely physician follow up; (4) provide a patient-centered health record including a plan of care for their recovery; and (5) assess the need for other supportive community resources such as home-delivered meals, volunteer transportation to medical appointments or medication assistance.
Program description
Sun Health transitional care program nurses were trained by a local Center for Aging on best practices in care transitions and geriatric specific screening tools. Sun Health coordinated the care transitions program and extended case management services into the community where the Sun Health transitional care nurses follows them home and ensures continuity of care. The program began with 3 RNs and 1 LPN. The nurse to patient staffing ratio was high in the beginning, so the intervention was very manageable. As the program expands, RN/LPN teams will manage a case load of 60 patients per month. Identification of planned discharges was initiated internally by the two hospitals who queried their electronic record systems daily. Utilizing this query as a starting point, Sun Health’s LPN, acting as in-hospital coaches, rounded daily at both hospitals and interfaced with designated CMs to review potential cases for inclusion in the care transitions program. Written materials developed by the CBO were available to share with patients as they considered participating in the care transitions program. Similar to the CTI, the Sun Health care transitions program focused on four key areas including: (1) medication self-management, (2) the use of a paper-based personal health record (PHR) by the patient or caregiver to facilitate communication and ensure continuity of the care plan across providers and settings, (3) ensuring timely follow-up visits with the receiving care teams, and (4) educating patients on red flags indicating worsening of their condition. The Sun Health care transitions program was also expanded to include depression and mobility screening using the PHQ-2 [23] and the timed ‘Up and Go’ test, respectively [24]. Patients received an initial phone call on the day of discharge or the day following discharge to set up their initial home visit within 24 to 48 hours. A home visit by the RN occurred, ideally, within 24–48 hours post-discharge. The initial home visit was then followed by three to five phone calls at various times during the 30-day post-discharge period, depending on the needs of the patient (Figure 1). During the 30-day program, patients learned self-management skills and received customized tools to actively engage them in their care.
The initial home visit was where the care transitions program nurses addressed patient and/or caregiver training, developed patient-centered care plans, reconciled medications and provided medication education, ensured timely follow-up appointment were in place and arranged transportation as needed, and ensured that the patient and/or caregiver had necessary resources in place. Program teaching materials were identical to those used by the discharging institutions and helped to reinforce the patients’ learning. “Stoplight” diagrams illustrated condition red flags and when to contact a physician. Family and caregiver instruction were also provided. An assessment of the patient’s need for community based resources during the initial home visit and subsequent telephone interactions was performed. Referrals were made to available free or low-cost resources in the catchment area including home-delivered meals, medication assistance programs, medical equipment loan closets, volunteer transportation to medical appointments, volunteer grocery shopping, volunteer home maintenance, friendly visitor, telephone reassurance, and financial assistance programs. Referrals to post-hospital care services such as personal care/attendant services, geriatric case management services, skilled home care and hospice care were also available if needed. Patients were discharged from the program after they completed the 30 day post-hospitalization program or if they elected to end services sooner. Discharge summaries were written by the RNs and kept in the patient’s encounter form and were shared with the patient’s PCP.