2062. Seamless Care: Transitional Health Care from Hospital to Home
AM Spehar, VA Patient Safety Center, James A. Haley VAH, Tampa, FL, and College of Public Health, University of South Florida, D Scott, University Community Hospital, Tampa, FL, P Palacios, VA Patient Safety Center, James A. Haley VAH, J Baker, University Community Hospital, Tampa, FL, D Werner, VA Patient Safety Center, James A. Haley VAH

Objectives: Our ultimate goal is to improve patient outcomes during the critical transition from institution to home. By identifying and targeting high-risk patients within two hospital systems, and developing models to improve the discharge process, we hope to maximize improvement in post-discharge patient outcomes, as well as patient, caregiver and provider satisfaction.

This study is the first phase of research to identify factors and processes that can be effectively targeted in the design of interventions addressing:  a. What patient-associated risk factors (e.g., age, race/ethnicity, sex, marital status, diagnoses, insurance) are associated with unscheduled hospital readmissions within 30 days post-discharge?  b. What organizational processes (e.g., discharge planning, communication, medication management) facilitate or impede seamless care during the transition from hospital to home?

Methods: Three Diagnosis Related Groups (DRG) were targeted using extant administrative databases for FY 2001, 127 Heart Failure, 89 Pneumonia (>17y), and 109 CABG without catheterization. Selection was based on being in the top 12 readmissions at both institutions, significant percent readmission and costs, being quality indicators for JCAHO and FMQAI, and likelihood of successful interventions. Research design was a multi-method analysis using administrative databases, focus groups, root cause analysis, and review of medication management.

Results: For both institutions, the average age of the 3 DRG groups was >60y, but minorities varied from 5-24%. Communication deficiencies at admission, during hospitalization, and on discharge, medication management, institutional procedures, and communication with outside providers were identified as potential targets for interventions. Readmission costs, length of stay, average age, and race/ethnicity at both institutions were similar.Differences in patient profiles between those readmitted and not were evaluated within each institution, as hospital processes and structures differed considerably.

Conclusions: Targeting interventions to improve communication, medication management and “hand offs” between providers can potentially lead to more seamless care.  The populations at risk for readmission at both institutions were more similar than different, despite different hospital systems.

Impact: Comparison of three DRG readmissions at one VA and one private hospital permitted us to design system interventions that should result in improved patient outcomes and provider satisfaction.  Our final recommendations about best practices from each institution should lead to improvements in 30-day readmission rates advantageous to their economic, administrative, and regulatory bottom line.  Since average direct cost of readmission for these DRGs was thousands of dollars per patient, any improvement should result in significant savings.