{"id":366,"date":"2024-11-06T16:38:50","date_gmt":"2024-11-06T16:38:50","guid":{"rendered":"https:\/\/iims.uthscsa.edu\/isrn\/?page_id=366"},"modified":"2024-11-06T16:38:50","modified_gmt":"2024-11-06T16:38:50","slug":"implementing-a-transitional-care-model-to-reduce-readmissions","status":"publish","type":"page","link":"https:\/\/iims.uthscsa.edu\/isrn\/resources\/ereading-room\/abstracts\/implementing-a-transitional-care-model-to-reduce-readmissions\/","title":{"rendered":"Implementing a Transitional Care Model to Reduce Readmissions"},"content":{"rendered":"

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Primary Author:<\/td>\n\u00a0Patricia E. Moran, RN, ANP-C, DNP-student<\/td>\n<\/tr>\n
Organization<\/td>\n\u00a0Stony Brook University, School of Nursing<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Abstract<\/h2>\n

Purpose<\/h3>\n

The purpose of this study was to evaluate the effect of a care coordination model, designed to reduce readmission, on a group of transitioning at-risk elders. The goal of the model is to improve patient education, communication between inpatient and outpatient providers and implement timely follow-up visits.<\/p>\n

Background<\/h3>\n

It is estimated that the health care system could save $26 billion over ten years by decreasing hospital readmission. The Centers for Medicare and Medicaid Services would like a 20% reduction in hospital readmission rates by the end of 2013, which could prevent 1.6 million hospitalizations and save an estimated $15 billion. Beginning in fiscal year 2013, hospitals can expect denial of reimbursement for patients readmitted within 30 days for heart failure, pneumonia, or MI. Hospitals will have reimbursement reduced by 1% or less while penalties in 2014 and 2015 will be capped at 2% and 3%.<\/p>\n

Materials & Methods<\/h3>\n

The model was initiated on a 30-bed medical floor of an academic medical center over a six month period. Eligibility criteria included all male and female patients over 70 years of age, taking five or more medications, lived at home and discharged back to home.<\/p>\n

Results<\/h3>\n

All eligible patients (N=100) received the intervention and were included in the sample. Over the six-month period, readmission decreased from 19% to 15%. For 11% (n=11), of the sample, the index admission was a 30- day readmission. For this group 27.3% (n=3) were again readmitted within 30 days. Descriptive statistics were analyzed for the entire sample. Patients who were readmitted within 30 days and those who were not were also compared.<\/p>\n

Conclusion<\/h3>\n

Identifying high risk patients at the time of admission and coordinating care across transitions is integral to prevention of unnecessary readmission. Implementing a smooth transition from the hospital to the community, communication with primary care physicians, and improving patient and family readiness for discharge have a direct impact on hospital readmission rates.<\/p>\n

Bibliography<\/h3>\n

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Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-j. (2006). The Care Transitions Intervention. [Article]. Archives of Internal Medicine, 166(17), 1822-1828.<\/p>\n

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
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Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., et al. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA: Journal of the American Medical Association, 303(17), 1716-1722.<\/p>\n

Jacob, L., & Poletick, E. B. (2008). Systematic review: predictors of successful transition to community-based care for adults with chronic care needs. Care Management Journals, 9(4), 154-165.<\/p>\n

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare
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Kangovi, S., Grande, D. (2011). Hospital Readmissions-Not Just a Measure of Quality. Journal of American Medical Association, 306(16), 1796-1797.<\/p>\n

Kocher, R., Adashi, E. (2011). Hospital Readmissions and the Affordabel Care Act: Paying for Coordinated Quality Care. Journal of American Medical Association, 306(16), 1794-1795.<\/p>\n

Krumholz, H. M., Amatruda, J., Smith, G. L., Mattera, J. A., Roumanis, S. A., Radford, M. J., et al. (2002). Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. [doi: DOI:10.1016\/S0735-1097(01)01699-0]. Journal of the American College of Cardiology, 39(1), 83-89.<\/p>\n

Medicare Payment Advisory Commission. (2011, March). Hospital Inpatient and Outpatient Services. In Report to the Congress: Medicare Payment Policy (pp.37-65). Retrieved from\u00a0http:\/\/www.medpac.gov\/results.html?cx=011647704700448137656%3A4ktvy6n0gd…<\/a>
\n1&q=report+to+congress%3Amedicare+payment+policy+march+2011&sa=Search<\/p>\n

Scrutinize your readmissions and take steps to avoid them: CMS to begin penalizing hospitals when patients come back. (2010). Hospital Case Management, 18(2), 17-20.<\/p>\n

Society of Hospital Medicine. (2010). Retrieved from\u00a0www.hospitalmedicine.org\/BOOST<\/a><\/p>\n

Taylor, M. (2010). Shutting the door on readmissions: hospitals improve discharge and care transition procedures to reduce the need for patients to come back. H&HN: Hospitals & Health Networks, 84(1), 33.<\/p>\n

Van Walraven, C., Dhalla, I. A., Bell, C., Etchells, E., Stiell, I. G., Zarnke, K., et al. (2010). Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ: Canadian Medical Association Journal, 182(6), 551-557.<\/p>\n

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\u00a9 Improvement Science Research Network, 2012<\/p>\n

The ISRN\u00a0published this as received and with permission from the author(s).<\/p>\n<\/div>\n<\/div>\n<\/div>\n

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