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.
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.