1. DECREASING READMISSION THROUGH TRANSITIONAL CARE FROM SNF TO HOME
David Thimons, DO, CMD; Kristin Brockway, MD; Gerald Hartle, DNP, CRNP; Lisa Dusch, CRNP; Laura Mantine, MD
Heritage Valley Health Systems
QUALITY IMPROVEMENT METHODS
OBJECTIVE
A cohort study was designed using patients who were discharged from one of three skilled nursing facilities, all in Beaver County, Pennsylvania. Starting in November 2014 patients being discharged were offered a home visit by a physician or nurse practitioner if they lived within half an hour of the medical group’s office. Participants also received a 7, 15, and 30 day phone call to assess any needs. These patients were followed for 30 days to determine rates of readmission to the local hospital as compared to patients discharged within the same time frame who did not have home visits or phone calls. Measures collected were readmissions, Charlson Comorbidity Index (CCI), and number of medications on discharge. For the intervention group, medication errors and new physician orders were also tracked.
The aim is to decrease hospital readmission rates after discharge from skilled nursing facilities (SNF) by providing a home visit and a series of three phone calls.
BACKGROUND
Hospitals and SNF face growing financial pressure to decrease readmission rates1. Transitional care has proven effective for patients with chronic conditions across healthcare settings, typically from the hospital to home or from the hospital to SNF. However, it is rarely implemented when transitioning a patient from SNF to home. Many of these patients are placed in SNF after hospital discharge because of significant co-morbid conditions that place them at high risk for readmission, and many of the factors causing the risk are still present at discharge from SNF.
Medication Changes During Home Visits
CONCLUSIONS
The data yielded by this ongoing project is encouraging. Although not statistically significant, home visits conducted by physicians or nurse practitioners and follow-up phone calls will identify issues and errors. These can then be corrected and will decrease readmission rates of patients discharged from SNF to home. Our small study suggests transitional care from SNF to home should be further evaluated as a way to decrease readmission rates.
RESULTS
A total number of 135 patients were followed through the study period. Of these 55% were females. The average age of the patients was 72 years and CCI index was A total of 50 patients had home visits with follow-up data available. There were no significant differences between the intervention and comparison groups regarding age, sex, number of medications, or CCI. The baseline hospital 30-day readmission rate dropped from 13.1% to 4% in the intervention group. There were no significant differences in readmission rates based on sex, however there was a trend for greater readmission rates in patients with higher comorbidity index and greater age. In the intervention group there were 17 patients with a total of 25 medication errors identified; therefore, 34% of these patients had medication errors that needed corrected. Thirteen patients, 26%, required new physician orders during the home visit.
REFERENCES
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 360:
Toles M, Anderson RA, Massing M. Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge. J Am Geriatr Soc. 2014; 62(1):
Readmission Rates