Post-discharge intervention in vulnerable, chronically ill patients†
Article first published online: 15 NOV 2011
Copyright © 2011 Society of Hospital Medicine
Journal of Hospital Medicine
Volume 7, Issue 2, pages 124–130, February 2012
How to Cite
Kansagara, D., Ramsay, R. S., Labby, D. and Saha, S. (2012), Post-discharge intervention in vulnerable, chronically ill patients. J. Hosp. Med., 7: 124–130. doi: 10.1002/jhm.941
This work was supported by a grant from the Medical Research Foundation and with help from the Human Investigations Program at Oregon Health and Science University. Drs Kansagara and Saha were additionally supported by the United States Department of Veterans Affairs. The sponsors played no role in study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the paper for publication. None of the authors has a relevant conflict of interest.
- Issue published online: 6 FEB 2012
- Article first published online: 15 NOV 2011
- Manuscript Accepted: 7 MAY 2011
- Manuscript Revised: 1 MAY 2011
- Manuscript Received: 14 DEC 2010
- continuity of care;
- quality improvement;
- transition and discharge planning
Studies suggest that the inpatient to outpatient transition of care is a vulnerable period for patients, and socioeconomically disadvantaged populations may be particularly susceptible.
In this prospective cohort study, clustered by hospital, we sought to determine the feasibility and utility of a simple, post-discharge intervention in reducing hospital readmissions.
Chronically ill Medicaid managed care members were consecutively identified from the discharge records of 10 area hospitals. For patients from the 7 intervention hospitals, trained medical assistants performed a brief telephone needs assessment, within 1 week of discharge, in which issues requiring near-term resolution were identified and addressed. Patients with more complicated care needs were identified according to a 4-domain care needs framework and enrolled in more intensive care management. Patients discharged from the 3 control hospitals received usual care. We used a generalized estimating equation model, which adjusts for clustering by hospital, to evaluate the primary outcome of hospital readmission within 60 days.
There were 97 intervention and 130 control patients. Intervention patients were slightly younger and had higher adjusted clinical group (ACG) scores. In unadjusted analysis, the intervention group had lower, but statistically similar, 60-day rehospitalization rates (23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24-1.00].
A simple post-discharge intervention and needs assessment may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse care needs. Journal of Hospital Medicine 2012;. © 2011 Society of Hospital Medicine