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Keywords:

  • health reform;
  • heart failure;
  • home healthcare;
  • rehospitalization;
  • transitional care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high-risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high-risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

The newly enacted Patient Protection and Affordable Care Act (PPACA) seeks to reign in health system costs by exploring innovative approaches to delivering high-quality, cost-effective healthcare in the United States. Many of the most costly and inefficient aspects of medical care are found among chronically ill patients who have histories of frequent readmission to hospitals. Recent research has focused on opportunities to reduce costs and improve outcomes by promoting transitional care for these complex patients as they are discharged from the hospital and transferred to community-based care settings. The present article discusses a recent initiative at a large not-for-profit Certified Home Healthcare Agency, to collaborate with a hospital in providing transitional care services to high-risk heart failure patients. This initiative is unique in that it is integrated into both hospital discharge and home health services. We discuss the development and implementation of this initiative, and describe the specific characteristics of transitional care services that are provided to patients. As a preliminary evaluation of the impact of this intervention on patient outcomes, we describe the results from an analysis that compares the likelihood of rehospitalization among patients who received the transitional care services and a similar group of patients who received usual home care services at a single regional hospital. Following a summary of the results from this analysis, we discuss the opportunities and challenges associated with implementing this pilot program.

The Role of Transitional Care

Transitional care refers to the continuous and coordinated transferring of patients from one care setting to another (Coleman & Berenson, 2004). Transitional care can include: (1) logistical arrangements of patient care from the point of hospital admission through discharge to the home or community, (2) communication and coordination among healthcare professionals involved in patient care, (3) education of the patient and family, and (4) detailed assessments of patient health status and preferences for healthcare (Coleman, 2003; Naylor & Sochalski, 2010). A growing body of literature suggests that providing transitional care services to patients who require care across multiple settings has a positive impact on patient outcomes (Coleman, Parry, Chalmers, & Min, 2006; Daley, 2010). For instance, results from a randomized controlled trial indicated that patients who received a transitional care intervention (e.g., assistance with medication self-management, maintenance of a personal health record, follow-up care, education of “red flags” that condition is worsening) had lower rehospitalization rates than a group of control subjects (Coleman, Parry, Chalmers, & Min, 2006).

Those who benefit most from transitional care services have complex health problems and require frequent care in multiple settings (Coleman, 2003; Coleman & Boult, 2003). For instance, patients who have continuous complex care needs often require clinical attention and personal care assistance after they are discharged from a hospital. Home healthcare often fills this role by providing professional and supportive services (e.g., skilled nursing, rehabilitation, home health aides) that enable these patients to manage their conditions and remain at home. Home healthcare patients tend to be clinically complex—a majority has multiple chronic conditions and cognitive impairments that present challenges to care planning and management (Murtaugh et al., 2009). However, only a minority of home healthcare patients receives comprehensive care planning and management during the transitional period following hospital discharge (Coleman, 2003; Naylor, 2006).

One group of clinically complex patients who are likely to benefit from transitional care services includes those with congestive heart failure. Heart failure is the leading cause of hospitalization among adults aged 65 or older in the United States (Agency for Healthcare Research & Quality, 2007). Patients with heart failure also tend to have one of the highest, if not the highest, rehospitalization rates (Jencks, Williams, & Coleman, 2009; Ma, Lum, & Woo, 2006). Despite this pattern, a substantial proportion of repetitive hospitalizations among heart failure patients is believed to be preventable (Vinson, Rich, Sperry, Shah, & McNamara, 1990). A qualitative study of medical research files among older heart failure patients identified three major factors that contribute to readmission—including difficulty in maintaining a supply of medications, inability to change dietary habits, and poor general health behaviors (Happ, Naylor, & Roe-Prior, 1997). These factors are likely to originate from low levels of knowledge about heart failure and self-care management (Strömberg, 2005). Comprehensive transitional care interventions that emphasize coordination between healthcare providers, patient education, and self-care management may address some of these issues and reduce rates of rehospitalization in this population (Daley, 2010; Naylor et al., 2004).

A Collaborative Transitional Care Initiative for Heart Failure Patients

The Heart Failure Transitions Program, a partnership between a Certified Home Healthcare Agency and a regional hospital, provides transitional care services to patients with congestive heart failure. With pay-for-performance financial incentives on the horizon, hospital administration staff and quality improvement experts (based at the home healthcare agency) sought to reduce hospital readmissions among heart failure patients by coordinating efforts between the two organizations and implementing evidence-based transitional care practices. Four collaborative aims were developed for the program, which begins prior to patient discharge from the hospital and continues through the transition to skilled home healthcare services. The aims include: (1) identifying and assessing caregivers to determine their needs for education and support, (2) integrating caregivers into the team of healthcare providers involved in the patient's plan of care, (3) building communication bridges between patients, providers, and caregivers, and (4) “closing the loop” with all parties involved in the patient's care. The key components of the initiative are summarized in Figure 1.

image

Figure 1. Key Components of the Heart Failure Transitions Program

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A primary objective of the present study is to evaluate whether patients who receive the transitional care services provided through the program are less likely to be rehospitalized compared to a similar group of patients from the same hospital who received usual care prior to the program's implementation. We hypothesize that program participation is associated with a reduced odds of rehospitalization within 30 days of admission to the home healthcare agency.

Data and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

We conducted a retrospective observational study to compare the likelihood of hospital readmission among heart failure patients who received the transitional care services through the collaborative initiative and a similar group of patients who received usual home care services (e.g., skilled nursing, physical therapy, home health aide). All patients selected for the study were referred from a single large not-for-profit general medical and surgical hospital in New York City. Patients were categorized into two study groups—an intervention group and a control group. The intervention group (n = 223) includes heart failure patients who received the various components of the Heart Failure Transitions Program during the first three quarters of 2010. The control group (n = 224) includes patients with a primary or secondary diagnosis of congestive heart failure who received usual home care services during 2009 (i.e., patients who did not receive the transitional care components discussed in the previous section). Patients in the intervention and control groups were selected from different time periods in an effort to reduce contamination bias by ensuring that patients in the control group were not exposed to the intervention. Additionally, patients selected for both groups had a high likelihood of being hospitalized based on a validated predictive model of hospitalization risk that takes into account demographic, financial, clinical, and health status factors at the start of home healthcare services (Rosati & Huang, 2007). We chose this method of selection for two reasons: (1) including those with a similar level of hospitalization risk at the start of home healthcare minimizes any differences in patient characteristics between the intervention and control groups; and 2) an important aim of the study is assessing whether the Heart Failure Transitions Program is effective in reducing rehospitalization risk among the most clinically complex patients who have a high likelihood of hospitalization at the point of admission to home healthcare.

Data for the study were collected from the plan of care, electronic medical records, and the Outcomes Assessment Information Set (OASIS). A range of patient characteristics was included in the analysis for use as control variables in the adjusted logistic regression model. Demographic characteristics that were assessed included age (coded in years), sex (male = 0; female = 1), and race/ethnicity (white non-Hispanic, African American, Hispanic, and Asian/Other Race). Other health conditions and risk factors that were measured included obesity and hypertension (based on ICD-9 codes), and the number of comorbidities (minimum of two and maximum of six diagnoses). Service utilization characteristics included length of service (measured as the number of days between the beginning and end of the home healthcare episode), average number of nursing visits per week, and whether patients were receiving physical therapy (receiving physical therapy = 1; not receiving physical therapy = 0) or home health aide services (receiving home health aide services = 1; not receiving home health aide services = 0).

The primary outcome measure employed in this study was rehospitalization within 30 days from the beginning of the home healthcare episode. Approximately, 28% of cases in the analytic sample were readmitted to the hospital one or more times during this period. This indicator is consistent with the measure utilized by the U.S. Department of Health and Human Services to compare outcomes among heart failure patients across hospitals (U.S. Department of Health and Human Services, 2010).

The analytic approach involves two steps. The first step is descriptive and compares demographic and clinical characteristics among patients in the intervention and control groups. Two-tailed t-tests are employed to assess whether there are statistically significant differences between the intervention and control groups among the continuous control variables. Chi-square tests are employed to evaluate significant differences between the study groups among the categorical control variables. The second step of the analysis is to evaluate the association between participation in the Heart Failure Transitions Program and odds of rehospitalization within 30 days of admission to home healthcare. Two logistic regression models were estimated. The first model estimates the unadjusted odds (without controls) of rehospitalization for the intervention group compared to the control group. The second model estimates the adjusted odds (including controls for patient demographic and clinical characteristics) of rehospitalization for the intervention group compared to the control group. All statistical analyses are conducted using SAS version 9.2 (SAS Institute Inc., Cary, NC).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

A comparison of unadjusted patient characteristics across the intervention and control groups is presented in Table 1. Patients in both groups have an average age of approximately 79 years and the majority is white non-Hispanic (57% of patients). A substantial minority of patients is obese (16%) and has hypertension (14%). The average number of comorbidities is also high (mean = 5.4 of a maximum of six diagnoses; standard deviation = 0.9), illustrating the clinical complexity of this patient population. Two significant differences between the intervention and control groups were identified. First, patients in the intervention group have significantly more comorbidities than patients in the control group. Second, a greater proportion of patients in the intervention received physical therapy services. More than 70% of patients in the intervention group received these services compared to only 45% of patients in the control group.

Table 1. Descriptive Characteristics for the Total Sample and by Study Group
 Total SampleIntervention GroupControl Group
Study Variable(N = 447)(n = 223)(n = 224)
  1. a

    Standard deviations are presented in the parentheses.

  2. *Two-tailed t-tests were employed to evaluate significant differences (p < .01) between the intervention and control groups across continuous variables and chi-square tests were employed to detect significant differences across categorical variables.

Age
 Average age79.7 (10.7)a79.4 (10.7)79.9 (10.7)
Sex
 Male43.444.442.4
 Female56.655.657.6
Race/ethnicity
 White non-Hispanic57.256.958.4
 African American16.817.016.5
 Hispanic14.514.814.3
 Asian/other11.011.210.7
Health conditions and risk factors
 Obesity15.714.517.0
 Hypertension13.913.014.7
 Number of comorbidities5.4 (0.9)5.6* (0.7)5.3 (0.9)
Service utilization
 Length of service in days39.5 (42.0)38.3 (36.1)39.4 (44.8)
 Average nursing visits/week1.1 (1.2)1.2 (1.3)1.2 (1.3)
 Receiving physical therapy services57.570.4*44.6
 Receiving home health aide services30.232.727.7

Next, we examined whether patients enrolled in the transitional care program have a lower risk of hospital readmission compared to the control group after adjusting for demographic, clinical, and service utilization characteristics described in Table 1. The results of a logistic regression equation addressing this research question are presented in Table 2. The adjusted odds ratio for 30-day rehospitalization among those in the intervention group was 0.57 (p < .01), indicating that heart failure patients who received the transitional care services were 43% less likely to be readmitted to a hospital compared to a similar group of patients who received usual home care services.

Table 2. Unadjusted and Adjusted Odds Ratios for 30-Day Hospitalization (N = 447)
 Unadjusted Odds Ratio
Note
  1. The equation that produced the coefficient for the adjusted odds ratio includes controls for demographic characteristics, health conditions and other risk factors, and service utilization. Significant odds ratios (p < .01) are highlighted in bold text.

Control groupReference
(n = 224)
Intervention group0.58
(n = 223; 95% Confidence interval)(0.38–0.88)
 Adjusted Odds Ratio
Control groupReference
(n = 224)
Intervention group0.57
(n = 223; 95% Confidence interval)(0.38–0.87)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

The recent enactment of the PPACA has directed increased attention toward the development of new patient care models to improve the quality and efficiency of healthcare. One provision included in this federal statute is the Community-Based Care Transitions Program. This program provides $500 million to support collaborative partnerships between hospitals and community-based organizations that extend transitional care services to Medicare beneficiaries with complex health problems who have a high risk of hospital readmission (AARP Public Policy Institute, 2010; Coleman & Berman, 2010). Transitional care models present many opportunities to both hospitals and community-based organizations to improve the quality of care for complex patients. Those with congestive heart failure represent one of the largest, and most risk-prone, groups of patients shared across healthcare settings. As more public and private insurers adopt financial incentives for hospitals to encourage improvement in clinical care and patient outcomes (e.g., pay for performance), providing transitional care services to complex patients can offer a cost-effective method to reduce hospital readmissions (RAND Health COMPARE, 2010).

The findings presented here suggest that patients who received transitional care services through a collaborative initiative between a regional hospital and home healthcare agency are significantly less likely to be readmitted to the hospital. We believe that the Heart Failure Transitions Program is innovative in the way that it is integrated into both the hospital discharge process as well as the skilled services provided by a Certified Home Healthcare Agency. The study results provide additional support for home healthcare agencies to design new evidence-based initiatives around transitional care and chronic disease management (Hall & Morris, 2010). However, more research is needed to address the gaps and limitations of the present study. One important limitation of this study is the retrospective observational study design. Although a multivariate model was employed to adjust for differences in patient characteristics across the intervention and control groups, the patients in these groups received care in different time periods, which could not be statistically controlled. Further research is needed to replicate the findings observed here using a randomized prospective design to minimize the influence of selection bias and extraneous factors. A second limitation of this study is that the analysis is based on patients from a single regional hospital and one home healthcare provider. Additional research should evaluate the impact of similar initiatives on patient outcomes across multiple hospitals to ensure the generalizability of results.

While this pilot initiative offers many opportunities to patients, caregivers, and the participating organizations, there are a number of challenges that can impede the development and implementation of similar programs. First, the process of collaboration among healthcare organizations can be challenging and involves a period of relationship building. This requires a substantial investment of time and effort on the part of both sides. In addition to the investment that is required to build partnerships across organizations, another challenge that emerged was the degree of fidelity to the transitional care model. Any successful initiative is dependent on the extent to which clinicians and administrative staff successfully implement the different components of the program, as well as the receptivity of patients and caregivers to take responsibility for self-care management and education. For instance, clinicians and quality improvement experts who were involved in the program discussed issues such as ensuring that a self-care guide for the management of heart failure that is handed to patients in the hospital actually made it home with each patient.

In summary, our study provides some preliminary evidence of the potential for positive outcomes among heart failure patients when hospitals and home healthcare organizations work together to implement transitional care practices. Additional research is needed to fully understand the benefits of providing transitional care services to this patient population. A financial analysis that compares collaborative initiatives like the one discussed in this article to other transitional care interventions and services would be useful in determining the level of cost-effectiveness.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

The authors would like to acknowledge the efforts of Lorna DaSilva, Home Care Consultant Supervisor; Gloria DiFeo, Account Manager; Jeanne Haid, Quality Improvement Specialist; Marianne Kennedy, Regional Director; and Raymund Frogoso, Home Care Consultant from the Visiting Nurse Service of New York for their efforts in implementing the transitional care model at the pilot hospital. We are also grateful to Beth Costello, Statistical Analyst, for preparing the data and to Lindsay Pyc, Research Analyst, for assisting with the literature review and reference formatting

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at http://www.JHQce.org. This continuing education offering, JHQ 232, will provide 1 contact hour to those who complete it appropriately.

Core CPHQ Examination Content Area

III. Performance Measurement and Improvement

Learning Objectives and Multiple Choice Questions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies

Objectives

  1. Describe the four aims of the Heart Failure Transitions Program.
  2. Summarize the study findings regarding the odds of hospital readmission between the intervention and control groups.
  3. Identify two challenges associated with implementing the Heart Failure Transitions Program.

Questions

  1. _____ refers to the continuous and coordinated transfer of patients from one care setting to another.
    1. Accountable care
    2. Continuity of care
    3. Transitional care
    4. Comprehensive care
  2. _____ is the leading cause of hospitalization among adults aged 65 or older in the United States.
    1. Heart failure
    2. Pneumonia
    3. Hip fracture
    4. Stroke
  3. Which of the following choices is not one of the four aims of the Heart Failure Transitions Program?
    1. Assessing caregivers to determine their needs for education and support
    2. Integrating caregivers into the team of healthcare providers
    3. Building communication bridges between patients, providers, and caregivers
    4. Measuring the health status of caregivers
  4. The community-based partnership discussed in this article is between a hospital and _____.
    1. Skilled Nursing Facility
    2. Certified Home Healthcare Agency
    3. Community Health Clinic
    4. Inpatient Rehabilitation Facility
  5. All patients selected for the study were referred from a single general medical and surgical hospital in _____.
    1. Boston
    2. Los Angeles
    3. New York City
    4. Phoenix
  6. The primary outcome measure examined in this study was _____.
    1. Rehospitalization within 30 days of admission to home healthcare
    2. The number of comorbidities
    3. The length of service in home healthcare
    4. The number of nursing visits received per week
  7. The results of this study suggest that patients who receive transitional care services are _____ likely to be readmitted to the hospital compared to similar patients who do not receive these services.
    1. More
    2. Less
    3. Equally
    4. Similarly
  8. Which of the following choices was not discussed as a limitation in the methods of the study?
    1. Lack of valid outcome measures
    2. Analysis based on patients from a single regional hospital
    3. Patients receiving care in different time periods
    4. Retrospective observational study design
  9. The federal healthcare reform bill designates ____ million dollars to support collaborative partnerships between hospitals and community-based organizations that extend transitional care services to high-risk Medicare beneficiaries.
    1. 50
    2. 200
    3. 350
    4. 500
  10. The results of this study suggest that providing transitional care services to high-risk heart failure patients as they move between the hospital and home can be effective in addressing ______.
    1. Deterioration in physical functioning
    2. Symptoms of depression and anxiety
    3. Patterns of rehospitalization
    4. Poor self-management of chronic disease

Biographies

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data and Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Learning Objectives and Multiple Choice Questions
  10. Biographies
  • David Russell, PhD, is an Evaluation Scientist at the Center for Home Care Policy & Research, Visiting Nurse Service of New York. Dr. Russell works with research and administrative staff at the agency to design and implement evaluation studies of new programs and initiatives. His research interests include health services, medical sociology, and aging.

  • Robert J. Rosati, PhD, is Vice President of Clinical Informatics at the Center for Home Care Policy & Research, Visiting Nurse Service of New York. At the Center, Dr. Rosati is responsible for evaluating care delivery and reporting on clinical outcomes for all patients served by VNSNY. Dr. Rosati has over 20 years experience in healthcare and is currently on the faculty of Weill Cornell Medical College and Hofstra University. He also is a member of the JHQ Review Panel and Editorial Board.

  • Sally Sobolewski, MSN RN, is Director of Practice Improvement at the Visiting Nurse Service of New York. In her role, Ms. Sobolewski works with leaders and front-line staff in designing, testing, implementing, and evaluating ideas, strategies, and projects to achieve, exceed, and sustain quality measures that include publicly reported patient outcomes and the documentation of processes to improve patient care and safety. Ms. Sobolewski has collaborated on a number of projects with hospitals to improve the transition for patients and their caregivers from hospital to home.

  • Joan M. Marren, RN, MA, MEd, serves as Chief Operating Officer of the Visiting Nurse Service of New York and President, VNSNY Home Care. In her role, Ms. Marren ensures consistency in, and accountability for, implementation of agency strategy across the organization and its subsidiaries; serves as primary advocate and standard-bearer of quality; and directs service delivery, organizational design change, and QI efforts. Her leadership is characterized by a strong focus on innovation and practice improvement and she plays a significant role in shaping public policy. Ms. Marren was a 2004–2007 Robert Wood Johnson Executive Nurse Fellow.

  • Peri Rosenfeld, PhD, is a Senior Evaluation Scientist at the Center for Home Care Policy & Research, Visiting Nurse Service of New York. Dr. Rosenfeld's areas of research interest include aging, nursing workforce, access to care, and information literacy. She has published widely in these areas and is a review editor for several journals including CIN: Computers, Informatics and Nursing; Politics, Policy and Nursing Practice; and Medical Care. She is also a faculty member at the New York University College of Nursing.