Abstract — HSRD 2019


1124 — More is better: transitional care processes do reduce readmissions

Lead/Presenter: Jacqueline Pugh
All Authors: Pugh JA (STVHCS, UTHealthSA, Dole COE), Penney, LS (STVHCS, UTHealthSA), Noel, PH (STVHCS, UTHealthSA, Dole COE) Finley,E (STVHCS, UTHealthSA,Dole COE) Lanham,H (STVHCS, UTHealthSA,Dole COE) Mader, M (STVHCS, UTHealthSA,Dole COE) Leykum,L (STVHCS, UTHealthSA,Dole COE)

Numerous care transition processes (either alone or in combination) have been shown to reduce < 30d readmissions in trials. Using a list of effective processes derived from the literature, this observational study sought to assess whether the use of these processes in usual care was associated with lower readmission rates (RR).

Ten VA sites, chosen for 5-year trend of improving or worsening RR plus documented efforts to reduce readmissions, were assessed using a multimethod approach including on-site interviews and observations. 20 recommended processes were assessed (performed: not at all (0), inconsistently (1), in a limited subset of patients (2), or for all applicable patients (3). Total scores and individual process scores were tested for correlation with risk-adjusted RR for the 18 months surrounding the site visits.

Total scores ranged from 24-47 with a mean of 38.3. No site performed all processes for all applicable patients. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed for all patients at all facilities. Five processes scored 1 or 2 at all facilities: patient education throughout hospitalization, communication of medical plans in front of patients during physician team rounds, assessment of readmission risk, and availability of post-discharge home visit. The other 13 process scores varied more across facilities (range 0-3). Total care transition process score was correlated with risk adjusted RR (R2 = 0.54, p < 0.015). Three processes were significantly correlated with readmission: communication of medical plans in front of patients, medication reconciliation by pharmacists, and post-discharge patient hotline. Although enlisting social and community supports failed to reached significance (p = .06), the combination of communication of medical plans and enlisting social and community supports together resulted in an R-squared of 0.74 (p = .009).

Performing all recommended care transition processes consistently and for all patients for which they are applicable could further reduce early readmissions within VHA.

Further reducing readmissions in VHA will require more than making additional processes mandatory and should include more patient engagement through discussion of medical plans in front of patients and more engagement of community supports.