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The Patient-Centered Medical Home Multidisciplinary Intervention May Reduce Readmissions Among Older Adults

Rationale / Objectives

Older adults are a vulnerable population during transitions of care. Nearly one-fifth of hospitalized Medicare beneficiaries in Michigan are re-hospitalized within 30 days. These re-hospitalizations account for roughly $44 billion per year in hospital costs, three-quarters of which are potentially avoidable. The goal of this retrospective cohort study was to describe the characteristics and feasibility of implementing a multidisciplinary Patient-Centered Medical Homes (PCMHs) post discharge intervention program consisting of medical providers, clinical pharmacists, and social workers, and to determine the effect of the intervention on the rate of all-cause 30-day readmissions.

Project/Program Description & Major Achievements

PCMHs are designed to achieve the triple aim of higher quality, improved satisfaction, and lower costs through patient-centered, coordinated primary care. The Transitional Care Program (TCP) aims to do so by addressing the multidimensional needs of this complex population (medical, social, psychological, functional domains) and ensuring that treatment plans are personalized and implemented optimally using a team-based approach. The TCP, utilizing a clinical pharmacist, social worker, and medical provider, may reduce readmission rates among older patients when performed soon after discharge. The 30-day readmission rates were not significantly different between those scheduled for the intervention and those never scheduled (21% vs 17.3%, respectively; P = .133). However, when those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P <.001). Likewise, time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015) and potential cost avoidance was observed only when the intervention was completed”. The estimated savings was $737,673.

Lessons Learned

  • The effectiveness of TCP is dependent on completing the intervention.
  • Further research is needed to study outcomes of similar programs.
  • Resources to implement TCP may not be available in all clinic settings, and the current study is unable to determine if certain elements were more important than others in improving outcomes.

People / Organizations Involved

Further Description

The Transitional Care program (TCP) is operated from a geriatrics clinic, a community-based PCMH providing comprehensive, multidisciplinary primary and specialty care for patients 60 years and older. All hospitalized patients receive comprehensive discharge planning, medication reconciliation, and high-risk medication education. The TCP is scheduled for patients upon recommendation from consulted inpatient geriatrician services or for those receiving primary care at the geriatrics center. Appointments are scheduled within 1 week after discharge, coordinated with assistance from discharge planners, and included in discharge paperwork. The TCP team consists of medical providers (geriatric medicine physicians and nurse practitioners), clinical pharmacists, and social workers; the program was developed to assist patients transitioning to the community after unscheduled hospitalizations, long-term-care facility stays, or emergency department (ED) visits. The primary goal is to prevent re-hospitalization. The medical provider visit is the final component of the TCP. The medical provider performs a modified geriatrics assessment with focus on the reason for hospital admission, and in collaboration with the social worker, assesses the patient’s living situation, rehabilitation plan, caregiver network, and social support; patients’ self-care abilities and nutritional status are also assessed. Providers then review the goals of care with the patient, family, and caregivers. Lastly, follow-up appointments and referrals are coordinated. if patients receive primary care at the geriatrics center, primary care provider continuity is prioritized when scheduling appointments. Limitations of the study include potential under-reporting of readmission rates for those not in the same hospital and/or with multiple index hospitalizations. Important factors such as socioeconomic status, prior hospital utilization, self-management skills, home support, and level of education were not addressed nor was patient satisfaction.

Major Achievements

Over 27 months, 19,169 unique patients had 18,668 index hospitalizations and 572 interventions scheduled after discharge. Among matched subjects, 30-day readmission rates were not significantly different between those scheduled for the intervention and those never scheduled (21% vs 17.3%, respectively; P = .133). However, when those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P <.001). Likewise, time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015) and potential cost avoidance was observed only when the intervention was completed. The estimated savings was $737,673.

Metric Result Detail
30-day readmission rates between patients scheduled for the intervention 21% Case study: A Multidisciplinary Intervention for Reducing Readmissions Among Older Adults in a Patient-Centered Medical Home
Readmission rates between patients who completed the intervention 11.7%  
30-day readmission rates between patients never scheduled for intervention 17.3%  
Time to readmission among those receiving the intervention 18+9 days  
Time to readmission among those receiving regular care 12+9 days  
Cost savings after the intervention was completed $737,673