Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions

Courtney D Wellman; Adam M Franks; Morgan Stickler; William Rollyson; Alperen Korkmaz; Matthew Q Christiansen; Stephen M Petrany

doi:10.1093/fampra/cmad009

Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions

Fam Pract. 2023 Feb 2:cmad009. doi: 10.1093/fampra/cmad009. Online ahead of print.

Authors

Courtney D Wellman¹, Adam M Franks¹, Morgan Stickler¹, William Rollyson¹, Alperen Korkmaz¹, Matthew Q Christiansen¹, Stephen M Petrany¹

Affiliation

¹ Department of Family and Community Health, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States.

PMID: 36730038
DOI: 10.1093/fampra/cmad009

Abstract

Background: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions.

Methods: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission.

Results: Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis.

Conclusions: Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.

Keywords: care coordination; readmissions; transition of care.