Abstract
Introduction:
It is essential to provide transitional care to high-risk populations in their most vulnerable states through effective post-hospitalization follow-up. However, the effectiveness of virtual interventions could be established through the examination of adverse events, medical compliance, decreased hospital readmission rates, and cost-effectiveness.
Methods:
A new virtual post-discharge clinic was established to provide innovative multimodal interventions including education, identification of adverse events, medical adherence, social support, and coordination with primary care providers. We established innovated processes for referrals, scheduling, and communication for patients and stakeholders. Leadership was critical to sustaining transitional patient care for the organization while working with limited budgets.
Results:
Post-discharge visits were stratified based on the risk of readmission, and over 90% of patients received virtual appointments. Our interventions reduced the incidence of readmission by 33% among patients with a high risk of readmission; no differences were observed in patients with a low to medium risk of readmission.
Conclusion:
The effectiveness of telehealth transitional care interventions has a significant impact on reducing readmissions in high-risk populations. Our interventions provided comprehensive patient-centered care in the post-discharge setting.
Introduction
Post-acute care is becoming increasingly important for hospitals and value-based care organizations as a means of providing effective patient care. 1 Readmissions to hospitals can be costly and undesirable, with negative implications for both major payers and the public. 2 Hospitals participating in bundle-payer programs, such as those offered by the Centers for Medicare and Medicaid Services, and other major insurance providers, are publicly accountable for their costs and outcomes. 3 In addition, value-based care organizations that use risk-based payment systems are significantly impacted by high readmission rates, motivating them to invest in strong post-acute care initiatives. 4
High-risk patient populations and complex medical cases are often associated with increased readmission rates and poor outcomes, making timely intervention crucial in reducing the need for costly inpatient services. 5 However, even patients with less complexity can be affected by adverse events, such as medication errors and poor adherence to medical regimens, which can contribute to preventable readmissions. 6 It is estimated that over 20% of all hospitalized adult patients in the US experience adverse events within three weeks of discharge, with adverse drug events being the most common. 7 Communication breakdowns, information lapses, and unintended consequences often contribute to medication nonadherence, decreased disease management, limited follow-up on test results or treatment plans, and missed post-discharge follow-up visits. 8 Addressing these factors can significantly reduce the likelihood of preventable readmissions or emergency department return visits. 9 According to previous studies, approximately 23% of patients experience adverse events that could have been prevented by improved post-discharge and transitional care. 10 Effective post-acute care can help mitigate these risks and improve patient outcomes, making it a vital component of modern health care. 11
Post-acute care interventions are crucial for identifying adverse events, educating patients and their families about their medical conditions, ensuring medication adherence, and addressing social support needs. 12 In addition, these interventions aid in identifying and rectifying medical errors, coordinating care between primary care providers and specialists, and facilitating the shift from hospital to community-based care. 13 To achieve optimal outcomes, post-acute care programs must be customized to meet the unique needs of patients, hospitals, and stakeholders. 14 However, there is still much to be discovered regarding the impact of patient-centered variables, such as perceptions of hospital or post-discharge care, satisfaction with healthcare providers, and social support at home, on medication adherence and readmission rates.15–17 Although various organizations have implemented transitional initiatives, little is known about the internal operational processes associated with these efforts and their associated costs. In addition, diverse organizational settings, populations with different ethnic backgrounds and cultures, and varying availability of outpatient providers for follow-ups pose challenges to assessing the effectiveness of transitions and implementing single studies as a one-size-fits-all solution. Our academic institution has adopted a multifaceted approach to evaluating patient needs and delivering post-acute care, considering patient criteria, referral providers, institutional processes, major internal stakeholders, transitional care to primary care providers (PCPs), care coordination, data analysis, and financial considerations.
Methods
Strategic planning and implementation
This academic referral center faced several challenges, including the complex acute care needs of a diverse patient population, low rates of post-discharge follow-ups to PCPs in Southeast Chicago, and a significant number of patients who were out-of-network (OON). The center is comprised of two hospitals located on the same campus and has one of the largest hospitalist programs in the nation, a first-tier medical school, and multispecialty residency and fellowship programs. The center’s complex internal operational processes drive inpatient care and discharge.
Our strategy was to create simple and user-friendly processes for internal stakeholders to buy-in post-acute care interventions, referrals, and scheduling patients at a new post-discharge clinic (PDC). We established a shared folder in the electronic health record (EPIC) specifically for referral providers, where they can transfer patients from their patient census who require appointments at the PDC. Moreover, we granted the patient navigator coordinators (PNCs) direct access to the PDC providers’ schedules, enabling them to book appointments on the desired date and time for the patient. This arrangement provides patients with the convenience of selecting appointments without the need for central scheduling and without input from the patients, all available appointments are avoided. Furthermore, we facilitated a warm handoff to the PCPs through an EPIC communication letter, which includes a direct phone number to contact the PDC providers. During PDC visits, providers and supporting staff can provide patient and family education for medical adherence, identification of adverse events, medication reconciliation, and coordination of care, while enhancing inpatient patient experience. To address the most challenging and complex patients, we stratified the patients’ visits and intensity of interventions for those at a high risk of readmission. We used the Risk of Readmission score devised by the University of Chicago Medicine, which is a validated tool for assessing the risk of avoidable readmission within 30 days of discharge based on current patient data. The overall care provided extended beyond a PDC visit to the first 30 days after hospitalization. We also provided financial support for patients OON, as PDC visits were found to be more cost effective than having patients stay in the hospital, increasing the length of stay (LOS). The Finance office furnishes OON commercial insurance patients with the in-network medicare rate for transitional services. Inpatient case managers facilitate the prompt enrollment of qualified patients in medicaid services, operating as secondary insurance to avert out-of-pocket expenses for patients. All medicare patients OON are billed as in-network patients.
Leadership, internal resources, and limited budget
Launching a pilot or initiative is often accompanied by limited resources, including space and staffing. Nevertheless, every organization possesses a wealth of internal resources that can aid the project when they secure the support of key leaders who share their vision. Embarking on disruptive innovation is even more difficult in complex and well-established organizations, but these organizations are also rich in leadership and staffing. Our program-initiation approach was informed by our environmental assessment, as well as an analysis of inpatient scorecards and outpatient dashboards, which were both integral components of our strategic planning process. Furthermore, our extensive experience in this domain played a significant role in shaping our pertinent factors. We comprehensively evaluated all pertinent factors to ensure that our strategy was effective and well-suited to the task at hand. The following factors were considered:
Identify while addressing a gap in an organization’s quality, efficiency, or patient experience. Identify a clear vision for the organization. Align this vision with the organization’s annual goals. Understand the organization’s operational processes in relation to our project. Identify key leaders who can champion and advocate our project in executive leadership. Develop a comprehensive strategic plan that is cost-effective even if it does not generate revenue. Identify champions in data analytics and finance. Obtain support from upper leadership, even if we are an independent unit with leadership training and experience. Formulate a strategy in collaboration with a team, even if we have prior knowledge or experience of what needs to be done, and maintain a humble attitude, as we can always learn, particularly if we are new to the organization. Look beyond our internal stakeholders and plan for the future expansion of our horizons. Implement our project once we feel prepared and have gained support from major stakeholders. We learn from this process and avoid paralysis by being proactive. During the implementation phase, evidence, scorecards, research, and other relevant data are gathered to establish the project as an enterprise. Simplify and streamline our processes to make them more effective. Focus on marketing, recruitment, and expansion, while taking calculated risks. Provide feedback to stakeholders using data and reward those who work with us. Seek input from experts within the organization, regardless of our experience or expertise. Address gaps and issues in real time by conducting root cause analysis and Plan, Do, Check, Act cycles. Recognize our accomplishments and use data to support our claims. Monitor revenue and maintain a strong business acumen.
Operations and risk stratification
Our primary stakeholders included leaders of the Hospitalist Section and Department of Medicine, medical center leadership, ambulatory care, Finance, Office of Clinical Transformation, Quality Department, Case Management, Data Analytics, and Marketing. EPIC (Epic Systems, a prominent health technology firm situated in Verona, WI, specializing in the development of medical records software) has devised templates to facilitate the direct scheduling of both in-network and OON patients by PNCs into a PDC. Patients with a higher risk of readmission who were unable to see their PCP within 7 days of discharge were given priority for appointments in the PDC. For other patients at risk of readmission, appointments were scheduled within 14 days of hospitalization. Within 48 h of hospitalization, patients received a call from the transitional care management (TCM) team.
Out-of-network and transitional care management codes
For patients receiving care OON, the PDC operations team collaborated with the finance department to establish a standard process. This financial workflow served as a means of identifying OON PDC patients who required leadership approval before completing their PDC visits. The use of this exception was justified based on patient safety, provision of high-quality care, reduction in LOS, and minimization of the risk for 30-day readmission. Furthermore, by joining forces with the Population Health team and implementing video visits, the PDC could participate in TCM and bills using TCM codes. To qualify for TCM, three requirements must be met: (1) the complexity of the patient, (2) consultation with a population health nurse within 48 h of discharge, and (3) a PCP appointment scheduled within 14 days of discharge.
Post-discharge clinic
Our institution offers an innovative transitional care model developed through strong partnerships with multidisciplinary leadership and stakeholders. The model encompasses patient and family education on medical conditions, medication adherence, and coordination of care for future appointments and needs, as well as a seamless transition to PCPs. Our patient education approach is specifically designed to address hospitalization-related medical conditions, enhance patients’ understanding of their hospitalization experience, the treatments they received, and the importance of partnering with providers to continue managing their medical conditions. In addition, we educate patients on symptoms or signs that may require attention and could potentially lead to readmission. Patients and primary care providers received a letter emphasizing the points of care pending during the transition and a direct number to contact PDC providers for questions about hospitalization and transitional care. The foundations of our integrated transitional care model are the innovative processes that differentiate us from other institutions. Marketing efforts have primarily been carried out through presentations across the organization and PNCs to expand post-acute efforts from the Hospitalist Section to the General Medicine teaching service, short stay unit, and specialists.
Results and Discussion
Results
The Tableau dashboard (created by the University of Chicago Medicine Data Analytics Department) contains key metrics to track the performance of the PDC. These key metrics include the observed-expected length of stay
The readmissions of patients were analyzed based on their medical center risk of readmission scores, and the results were compared between patients who were evaluated and those who were not evaluated at the PDC. From December 2021 to November 2023, 503 patients completed their visits to the PDC. Among patients with high-risk scores, those who were seen at the PDC had a 33% decrease in the rate of readmissions. However, no significant difference was observed for patients with lower- or medium-risk scores (Table 1) (Fig. 1). In addition, the observed-ELOS
Third-day readmission rate by risk of readmission category.
Thirty-Day Readmission Rate by Risk of Readmission Category
PDC, post-discharge clinic.
Discussion
It is widely recognized that post-acute interventions that aim to reduce readmissions are most effective when they offer strong social support and coordination of care. It stands to reason that the most vulnerable patients, who are at the highest risk of readmission, are those who experience adverse events in the first 2–3 weeks following hospitalization. Patients are often readmitted to the hospital because of the development of adverse events, medication errors, or a lack of follow-up interventions or tests. Similarly, sicker patients may be less able to understand what happened during hospitalization and why their medications were changed. Unless the system is well-structured, medication errors can occur when the initial home medications are overlooked or only checked without visually verifying what the patient is actually taking and reconciling medications that have been changed by PCPs and specialists before hospitalization. Providers believe that they are taking the necessary steps to ensure that their care is provided accurately, but the health care system does not always work as expected, and electronic health records can be easily overlooked with a simple checkmark indicating an underlying medication error during admission. Moreover, once patients are discharged from the hospital, their need for coordination of social support, transportation, and other services is no longer monitored. Post-acute care interventions aim to fill these gaps and provide a comprehensive approach following hospitalization. There are various post-acute care models available, ranging from a single visit after discharge to an extended program that offers comprehensive intensity of services. Many of these programs are staffed by inpatient providers to facilitate a smooth transition to primary care providers. The objective of these services is to ensure that patients receive the care they require after leaving the hospital. Some programs may be more intensive than others, but all are designed to provide high-quality post-hospital care. According to Peter Long and colleagues at the National Academic of Medicine, successful care interventions for high-needs patients involve effective care, taxonomy and segmentation of patients, and care delivery models that address the delivery of care. This segmentation of inpatients with high risk of needs can result in a high risk of avoidable readmissions. 18 As such, care models that provide intensity of services, education, and medication reconciliation may be the right components in the transition of care for patients after hospitalization. The Society of Hospital Medicine has identified pathways to improve care transitions based on models that provide a suite of resources stratified for patients with risk of readmissions, adverse event identification, and care coordination.19–20 These findings align with several models, including Project RED (Re-Engineered Discharge) published by Boston University Medical Center.21–23
According to our data, the post-acute interventions provided at our medical center indicated an improvement in the quality of care and efficiency for high-risk patients. It is worth noting that patients seen at the PDC were discharged, reducing the LOS, although we were unable to capture bed-day savings because of inconsistent documentation at the time of discharge. Our post-acute interventions aim to decrease the LOS; however, early referrals to the emergency department or hospital enhance the quality of care and prompt early admissions, which would otherwise delay care and increase the LOS of patients.
From a financial perspective, shifting care from inpatient to outpatient settings greatly reduces the cost of DRG bundles, encourages early discharge, saves bed days, and improves inpatient capacity. In addition, this change can increase revenue through TCM coding and facility charges. Furthermore, it promotes a culture of doing the right thing to patients at the right time.
Conclusion
Post-hospitalization care offers a range of opportunities for patients, such as education on their condition, adherence to medical regimens, identification and intervention of adverse events, coordination with PCPs, and social support. These interventions have been shown to reduce hospital readmissions in high-risk patients. Telehealth provides a cost-effective means of achieving these outcomes, but larger studies are needed to obtain definitive evidence. The limitations of the study included the small number of patients with high inpatient readmission scores.
Ethical Compliance
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Data Access Statement
Research data supporting this publication are available from the University of Chicago Medicine Data Analytics repository at located at https://edm.uchospitals.edu/#/site/main/views/PDCAnalysis/EDReturnsandReadmissionsbyRiskGroup?:iid=1
Footnotes
Author Disclosure Statement
The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this article.
Authors’ Contributions
G.R. and D.M. contributed to the design and implementation of the research, G.R., L.R., V.L., and K.R. to the analysis of the results and to the writing of the article. G.R. conceived the original and supervised the project.
Funding Information
The study was self-funded.