Aiming to Improve Readmissions Through InteGrated Hospital Transitions

BACKGROUND

Hospital inpatient care accounts for the largest share of total health care expenses in the US. In 2012, the average cost per inpatient stay was $10,400 with total aggregated hospital costs of $377.5 billion. (Moore, 2012; and Weiss, 2012) In addition to this expense, transitions from the hospital represent a particularly vulnerable time when patients are susceptible to experiencing adverse events, which is especially true for patients with complex chronic comorbidities. For example, twenty percent of Medicare patients are readmitted to the hospital within 30 days, and 20% of all discharged patients suffer from a preventable adverse event within three weeks of discharge.(Rennke, 2013) Despite national efforts to improve transitions, the hospital discharge process largely remains chaotic, fragmented, and associated with poor outcomes. (Rennke, 2013; Hansen, 2011; Jack, 2009; Kansagara, 2015; Kansagara, 2011; & Kripalani, 2014). Currently, even the highest risk patients leave a complex, acute hospital stay to then arrive in primary care offices that are often neither equipped nor resourced to manage the challenges inherent to such transitions. Indeed, transitioning the highest risk, complex patients will require a paradigm shift in care delivery that is intensive, multidisciplinary, coordinated, and encompasses wrap-around services.(http://www.isc.hbs.edu/health-care/vbhcd/Pages/integrated-practice-units.aspx.)

RATIONALE

To better enhance transitions of care for the highest risk, complex patients, Carolinas HealthCare System (CHS) has designed an Integrated Practice Unit, called Transition Services (CHS-TS). The IPU model is based on the concept that significant improvements in outcomes will come from physician-led, team based, integrated services that are focused on a specific condition or segment of the population.(http://www.isc.hbs.edu/health-care/vbhcd/Pages/integrated-practice-units.aspx) Also integral to the IPU model is having an advanced informatics platform to continuously measure costs, processes, and patient outcomes. CHS-TS aims to improve patient outcomes through innovative approaches that leverage analytics and technology, while bridging care coordination and communication gaps. During their hospitalization, CHS-TS patients enter into a transition pathway that includes the following key services: integrated access to medical, pharmacist, and specialty providers; access to CHS disease specific management programs; dedicated care management services delivered in home and at the clinic; lab and infusion services; palliative care consultations when appropriate; and paramedicine for 24 hour support. Because this population faces many barriers to accessing traditional care, CHS-TS leverages virtual technology to provide visits with patients in their home setting when necessary and appropriate. Whether virtual or in person, each patient will receive the following seven core components (the first four of which will be used as markers for the implementation (RE-AIM) evaluation:

(i) Introduction to CHS-TS process prior to discharge (ii) Hospital follow-up evaluation within 72 hours either in home with paramedicine or CHS-TS clinic (iii) Medication reconciliation by a pharmacist within 72 hours (iv) Weekly contact with care management team (v) Entry into the Heart Success Program if appropriate (vi) Access to 24/7 phone support, 24/7 paramedicine visits, and same day clinic scheduling (vii) Coordinated transition to the next appropriate care location after 30 days from time of discharge