A reengineered hospital discharge program to decrease rehospitalization: A randomized trial

Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts 02118, USA.
Annals of internal medicine (Impact Factor: 17.81). 03/2009; 150(3):178-87.
Source: PubMed


Emergency department visits and rehospitalization are common after hospital discharge.
To test the effects of an intervention designed to minimize hospital utilization after discharge.
Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.
General medical service at an urban, academic, safety-net hospital.
749 English-speaking hospitalized adults (mean age, 49.9 years).
A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.
Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.
Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.
This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.
A package of discharge services reduced hospital utilization within 30 days of discharge.
Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.

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    • "It has been suggested, but to our knowledge yet not tested, that patient-centered documentation could facilitate continuity of patient care [10]. Patient-centered care has been described as a quality [12] that contributes to the overall improvement of healthcare [13] [14] and that can reduce healthcare utilization [15] [16] [17]. Even though an agreed definition remains elusive and without consensus , Stewart et al. in one of the most cited definitions [18] defines patient-centered care as a set of components focusing on exploring both the disease and impact of the illness, acknowledging the patient with the goal of achieving common ground [19]. "
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    ABSTRACT: Background: Handovers between hospital and primary healthcare possess a risk for patient care. It has been suggested that the exchange of a comprehensive medical record containing both medical and patient-centered aspects of information can support high quality handovers. Objective: The objective of this study was to explore patient handovers between primary and secondary care by assessing the levels of patient-centeredness of medical records used for communication between care settings and by assessing continuity of patient care. Methods: Quantitative content analysis was used to analyze the 76 medical records of 22Swedish patients with chronic diseases and/or polypharmacy. Results: The levels of patient-centeredness documented in handover records were assessed as poor, especially in regards to informing patients and achieving a shared understanding/agreement about their treatment plans. The follow up of patients’ medical and care needs were remotely related to the discharge information sent from the hospital to the primary care providers, or to the hospital provider’s request for patient follow-up in primary healthcare. Link to full-text paper, available until April 28 2015:
    International Journal of Medical Informatics 01/2015; 84(5). DOI:10.1016/j.ijmedinf.2015.01.009 · 2.00 Impact Factor
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    • "To the individual clinician, implementing these findings may seem daunting. However, effective multi-domain models exist [8, 14, 18, 39] and nearly all provide options for substantial training. A recurring characteristic of these models is provision of a single health care provider responsive to multiple patient needs, thereby targeting multiple domains of the Ideal Transition of Care. "
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    ABSTRACT: Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions. Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework. 66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0). Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.
    BMC Health Services Research 09/2014; 14(1):423. DOI:10.1186/1472-6963-14-423 · 1.71 Impact Factor
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    • "Several studies that have shown decreases in hospital readmission rates, emergency department visits, and adverse drug events have included pharmacists as part of the multidisciplinary team.7-9 Pharmacists in all practice settings can serve an important role in providing continuity during TOC. "
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    ABSTRACT: Objective: To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC) models in the inpatient, ambulatory, and community practice settings. Methods: TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models. Results: Pharmacists are an essential part of the multidisciplinary team and play a key role in providing care to patients as they move between health care settings or from a health care setting to home. Pharmacists can participate in many aspects of the inpatient, ambulatory care, and community pharmacy practice settings to implement and ensure optimal TOC processes. This article describes establishing the pharmacist's TOC role and practicing within multiple health care settings. In these models, pharmacists focus on medication reconciliation, discharge counseling, and optimization of medications [corrected]. Conclusion: Optimizing the TOC process, reducing medication errors, and preventing adverse events are important focus areas in the current health care system, as emphasized by The Joint Commission and other health care organizations. Pharmacists have the unique opportunity and skillset to develop and participate in TOC processes that will enhance medication safety and improve patient care.
    Pharmacy Practice 04/2014; 12(2):439. DOI:10.4321/S1886-36552014000200001
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