Transition Coach Program Implementation Associated with Thirty-Day Readmission Rates in a Community Hospital Setting
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Abstract
Background: With implementation of Medicare policies affecting reimbursement for readmissions, there has been increased emphasis on quality of care during transition from hospital to home. Several models for improved care, such as utilization of transition coaches, have developed to address barriers to quality healthcare that are prevalent in this care transition.
Objective: To study the effect of implementation of a transition coach program on thirty-day readmission rates in a community setting serving a predominantly low-income patient population.
Design: Retrospective cohort study. 30-day readmission rates of control group were compared to group receiving transition coach services. Retrospective cohort study. 30-day readmission rates of control group were compared to group receiving transition coach services.
Setting: 189-bed community hospital.
Patients: Medicare or dually-eligible patients admitted between 2/1/12 and 1/31/14.
Intervention: Intervention group received transition coach services, including inpatient assessment, at-home assessment and medication reconciliation, and telephone-based follow-up in the thirty days following index hospital admission.
Measurements: Data was gathered retrospectively on 30-day readmissions. After adjusting for age, gender, ethnicity, length of stay, and comorbidity, the odds of readmission were then assessed through logistic regression.
Results: After adjusting for age, sex, length of stay, and comorbidity, odds ratio for readmission remained higher for those receiving transition coach services, with 30-day odds ratios of 1.55 (95% CI: 1.15-2.08, p = 0.004) during year one and 1.88 (1.40-2.53, p < 0.001) during year two.
Conclusions: Though limited by design, it did not appear that use of transition coaches among a high-risk elderly population decreased rates of all-cause readmission in this community setting.
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Copyright (c) 2016 Moore II RA, et al.
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Kohn LT, Corrigan JM, Donaldson MS (2000) To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press .
Donaldson MS, Kohn LT (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press .
Coleman EA, Boult E (2003) Improving the Quality of Transitional Care for Persons with Complex Care Needs. J Am Geriatr Soc 51: 556-557 .
Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, et al. (2004) Adverse Events among Medical Patients after Discharge from Hospital. CMAJ 170: 345-349 .
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2003) The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med 138: 161-167 .
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, et al. (2000) Deficits in Communication between Hospital-Based and Primary Care Physicians. JAMA 2007; 297: 831-841 .
Moore C, McGinn T, Halm E (2007) Tying Up Loose Ends: Discharging Patients with Unresolved Medical Issues. Arch Intern Med 167: 1305-1311 .
Jencks S, Williams M, Coleman E (2009) Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360: 1418-1428 .
Kane RL (2009) What Can Improve Chronic Disease Care? J Am Geriatr Soc 57: 2338-2345 .
Coleman EA, Parry C, Chalmers S, Min SJ (2006) The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 166: 1822-1888 .
Parrish MM, O'Malley K, Adams RI, Adams SR, Coleman EA (2009) Implementation of the Care Transitions Intervention: Sustainability and Lessons Learned. Prof Case Manag 14: 282-293 .
Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB (2011) The Importance of Transitional Care in Achieving Health Reform. Health Affairs 30: 746-754 .
Kind AJ, Jensen L, Barczi S, Bridges A, Kordahl R, et al. (2012) Low-Cost Transitional Care with Nurse Managers Making Mostly Phone Contact with Patients Cut Rehospitalization at a VA Hospital. Health Affairs 31: 2659-2668 .
Brand CA, Jones CT, Lowe AJ, Nielsen DA, Roberts CA, et al. (2004) A Transitional Care Service for Elderly Chronic Disease Patients at Risk of Readmission. Aust Health Rev 28: 275-284 .
Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, et al. (2009) A Reengineered Hospital Discharge Program to Decrease Rehospitalization. Arch Intern Med 150: 178-187 .
Berkowitz RE, Fang Z, Helfand BK, Jones RN, Schreiber R, et al. (2013) Project ReEngineered Discharge Lowers Hospital Readmissions of Patients Discharged from a Skilled Nursing Facility. J Am Med Dir Assoc 14: 736-740 .
US Census Bureau 2012 Statistics.
(2013) HCUP Comorbidity Software, Version 3.7. Healthcare Cost and Utilization Project (HCUP). July 2013. Agency for Healthcare Research and Quality, Rockville, MD .
Joynt K, Jha A (2012) Thirty-Day Readmissions, Truth and Consequences. N Engl J Med 366: 1366-1369 .
LaMantia MA1, Scheunemann LP, Viera AJ, Busby-Whitehead J, Hanson LC (2010) Interventions to Improve Transitional Care between Nursing Homes and Hospitals: A Systematic Review. J Am Geriatr Soc 58: 777-782 .
Smith SM, Allwright S, O'Dowd T (2007) Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database of Systematic Reviews CD004910.
Weinberger M, Oddone E, Henderson W (1996) Does Increased Access to Primary Care Reduce Hospital Readmissions? N Engl J Med 334: 1441-1447 .