There has been considerable interest in development of strategies to reduce avoidable readmissions after hospital discharges. Studies have shown that home visits after discharge can result in readmission prevention, improved patient satisfaction, understanding and compliance. However, this intervention can be resource intensive. By coupling postdischarge home visits to a readmission prediction tool, we can target high intensity interventions specifically for patients who are at substantial risk of readmission. This strategic approach has resulted in significantly decreased 30 day readmissions and emergency department (ED) utilization for this patient population.
This study was performed at a community hospital in an urban location. Patients were eligible for inclusion, if they were followed by the hospital medicine service and were discharged to home without home nursing services. Patients were placed into minimal, low, moderate, or high risk of readmission groups based on their calculated readmission risk scores. Sixty consecutive patients in the moderate and high risk groups were randomized to receive a home visit or routine posthospitalization care. Home visits were performed by a nurse practitioner within 72 h of discharge and included a targeted physical examination, inperson medication reconciliation, clinical assessment, and real time adjustment of medications and care plans. Routine posthospital care included phone calls and primary care physician followup within one week of discharge. Patients were tracked for hospital readmission and ED visits for 30 days after the index admission.
Thirtyone patients were seen by the study nurse practitioner in the home, while 29 patients had standard post discharge followup. Patients who were seen in the home were 18% less likely to be readmitted to the hospital and 25% less likely to utilize the ED. Overall, the rate of hospital utilization (readmissions + ED visits) decreased by 58% compared to patients receiving standard postdischarge care. Moreover, if patients in the intervention group were readmitted, the average length of the readmission stay was substantially decreased (2.8 days vs 6.7 days). Patients in the intervention group had significantly improved understanding of their health issues compared to those patients who received routine postdischarge care.
By coupling a risk of readmission tool to an effective posthospitalization transition intervention, resources can be allocated to those patients who can most benefit from intensive posthospitalization follow up. This targeted approach reduced readmission rates, decreased length of stay when a patient was readmitted, decreased ED utilization, and improved patient understanding and satisfaction.
To cite this abstract:Vellinga B, Smith J, Bland L, Novelli M. Targeting Posthospitalization Interventions to Reduce 30 Day Readmissions and Emergency Department Utilization in High Risk Populations. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97545. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/targeting-posthospitalization-interventions-to-reduce-30-day-readmissions-and-emergency-department-utilization-in-high-risk-populations/. Accessed January 23, 2020.