Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment (original) (raw)
Related papers
Clinical Interventions in Aging, 2013
Purpose: Patients leaving the hospital are at increased risk of functional decline and hospital readmission. The Employee and Community Health service at Mayo Clinic in Rochester developed a care transition program (CTP) to provide home-based care services for medically complex patients. The study objective was to determine the relationship between CTP use, 30-day hospital readmission, and Emergency Room (ER) visits for adults over 60 years with high Elder Risk Assessment scores. Patients and methods: This was a pilot prospective cohort study that included 20 patients that used the CTP and 20 patients discharged from the hospital without using the CTP. The medically complex study patients were drawn from the department of Employee and Community Health population between October 14, 2011 and September 27, 2012. The primary outcomes were 30-day hospital readmission or ER visit after discharge from the hospital. The secondary outcomes were within-group changes in grip strength, gait speed, and quality of life (QOL). Patients underwent two study visits, one at baseline and one at 30 days postbaseline. The primary analysis included time-to-event from baseline to rehospitalization or ER visit. Paired t-tests were used for secondary outcomes, with continuous scores. Results: Of the 40 patients enrolled, 36 completed all study visits. The 30-day hospital readmission rates for usual care patients were 10.5% compared with no readmissions for CTP patients. There were 31.6% ER visits in the UC group and 11.8% in the CTP group (P = 0.37). The secondary analysis showed some improvement in physical QOL scores (pre: 32.7; post: 39.4) for the CTP participants (P , 0.01) and no differences in gait speed or grip strength. Conclusion: Based on this pilot study of care transition, we found nonsignificant lower hospital and ER utilization rates and improved physical QOL scores for patients in the CTP group. However, the data leads us to recommend future studies with larger sample sizes (N = 250).
Medical Care, 2018
Background-Care transitions programs have been shown to reduce hospital readmissions. Objectives-Evaluate effects of the Mayo Clinic Care Transitions program (MCCT) on potentially preventable and non-preventable 30-day unplanned readmissions among high risk elders. Research Design-Retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care. Subjects-Primary care patients ≥60 years, at high risk for readmission, hospitalized for any cause between January 1, 2011 and June 30, 2013. Measures-30-day hospital readmission. The 3M™ algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions (ACSCs), a subset of preventable readmissions identified by the 3M algorithm, were also assessed. Results-The study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83 years) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate (12.4% [95% CI, 8.9-15.7] vs. 20.1% [15.8-24.1]; p=0.004) resulting from a decrease in potentially preventable readmissions (8.4% [95% CI, 5.5-11.3] vs.
Journal of the Society for Social Work and Research, 2012
Discharge from hospital to home is a vulnerable period for older adults who have multiple care needs. The Safe Transitions for Elderly People (STEP) program is a care transition program for Medicare fee-for-service patients 75 years and older discharged to home from a community hospital. This quality improvement project (a) compares 30-day hospital readmission rates between 498 STEP participants and 722 patients eligible for STEP but not participating in the program, and (b) determines factors associated with readmissions during STEP. The STEP participants received intervention in 1 of 2 formats: 395 received a telephone-only intervention and 103 received a telephone plus home visit intervention. STEP participants had a lower 30-day hospital readmission rate than nonparticipants (i.e., those who could not be contacted for STEP participation; those who declined to participate). Results of binary logistic regressions showed 2 variables were significant predictors of readmissions: for the group of all STEP participants and the telephone-only intervention group, the (a) hospitalization within the previous year predicted readmission; for the telephone plus home visit group, the (b) degree of assistance needed with ambulation predicted readmission. Given the multifactor nature of readmissions, interdisciplinary teams should develop tailored interventions based on individual's psychosocial and medical assessments. Reforms to the Medicare fee-for-service system have the potential to change financial incentives that currently favor hospitalization of older patients, the potential to avoid readmissions, and the potential to direct the savings to support interdisciplinary care transition interventions.
Journal of hospital medicine, 2017
Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. Thirty-day r...
Journal of the American Medical Directors Association, 2021
HAL is a multidisciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. Distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives| 4.0 International License
European Journal of Internal Medicine, 2013
Background: Medical patients with a recent previous hospitalisation are at very high risk of subsequent readmission. Evidence suggests that improving key transition processes may reduce hospital readmissions. This study describes quality of transition processes in frequently admitted medical patients, to inform system improvements for this high risk group. Methods: Retrospective records review of consecutive medical inpatients aged 50 years or older in a major metropolitan teaching hospital in Australia with a recent (within 6 months) prior hospitalisation. Information was sought on 4 key processes: discharge summary completed and sent within 2 weeks; discharge medication reconciliation; patient/carer discharge education; and timely scheduling of outpatient review with the treating team. Readmission rates were obtained from a statewide admissions database. Results: Discharge processes for 209 live discharges in 164 patients were reviewed. Although timely discharge summary completion (81%) and discharge medication reconciliation by a pharmacist (81%) were high, there were major gaps in patient education (33%) and in timely outpatient review (12%). Outpatient systems appear poorly organised to support high quality transitions. Readmission rates were high (23% at 30 days and 58% at 180 days). Individual discharge quality processes did not predict readmissions. Discussion: Gaps in transitional care of frequently attending medical patients provide potential targets for improvement. In particular, opportunities for better patient/carer education and timely, structured outpatient review may inform design of improved transitions for this high risk group, to be tested in prospective controlled trials.
BMC Geriatrics, 2020
Background Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components’ role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes). Methods Randomized controlled trials (sample size ≥50 part...
Cost-Effectiveness of a Care Transitions Program in a Multimorbid Older Adult Cohort
Journal of the American Geriatrics Society, 2017
BACKGROUND/OBJECTIVES: Facing penalties for preventable 30-day hospital readmissions, many provider groups have implemented programs to remedy this problem, but the cost efficacy and value of such programs are not well delineated. The objective was to compare total cost of care over 30 days of individuals enrolled in the Mayo Clinic Care Transitions (MCCT) program and individuals not enrolled. DESIGN: Retrospective cohort study using secondary data analysis of a previously published cohort study. SETTING: Mayo Clinic, Rochester, Minnesota. PARTICIPANTS: MCCT participants (n = 363) and individuals in a propensity-matched referent cohort (n = 365). INTERVENTION: MCCT program enrollment. MEASUREMENTS: The primary outcome was total cost of care over 30 days after hospital discharge. A 2-part modeling strategy was used to analyze 30-day costs: whether individuals had non-zero costs during the 30 days after discharge and a generalized linear model for individuals who incurred costs. Potential heterogeneous effects of the MCCT program were examined according to decile of 30-day costs using quantile regression. RESULTS: Mean age was 83 in both groups.
Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults
BMC Health Services Research
Background: Acute hospital services account for the largest proportion of health care system budgets, and older adults are the most frequent users. As a result, older people who have been recently discharged from hospital may be at greater risk of readmission. This study aims to evaluate the comparative effectiveness of transitional care interventions on unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks following hospital discharge. Method: The present study was a randomised controlled trial (ACTRN12608000202369). The trial involved 222 participants who were recruited from medical wards in two metropolitan hospitals in Australia. Participants were eligible for inclusion if they were aged 65 years and over, admitted with a medical diagnosis and had at least one risk factor for readmission. Participants were randomised to one of four groups: standard care, exercise program only, Nurse Home visit and Telephone follow-up (N-HaT), or Exercise program and Nurse Home visit and Telephone follow-up (ExN-HaT). Socio-demographics, health and functional ability were assessed at baseline, 28 days, 12 weeks and 24 weeks. The primary outcome measure was unplanned hospital readmission which was defined as any hospital admission for an unforeseen or unplanned cause. Results: Participants in the ExN-HaT or the N-HaT groups were 3.6 times and 2.6 times respectively significantly less likely to have an unplanned readmission 28 days following discharge (ExN-HaT group HR 0.28, 95% CI 0.09-0.87, p = 0.029; N-HaT group HR 0.38, 95% CI 0.13-1.07, p = 0.067). Participants in the ExN-HaT or the N-HaT groups were 2.13 and 2.63 times respectively less likely to have an unplanned readmission in the 12 weeks after discharge (ExN-HaT group HR 0.47, 95% CI 0. 23-0.97, p = 0.014; N-HaT group HR 0.38, 95% CI 0.18-0.82, p = 0.040). At 24 weeks after discharge, there were no significant differences between groups. Conclusion: Multifaceted transitional care interventions across hospital and community settings are beneficial, with lower hospital readmission rates observed in those receiving more transitional intervention components, although only in first 12 weeks. Trial registration: Australian and New Zealand Clinical Trial Registry (ACTRN12608000202369).
recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of records for 736 536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white.