Integrated post-discharge transitional care in a hospitalist system to improve discharge outcome: An experimental study.
BMC Med. 2011 Aug 17;9(1):96
Authors: Shu CC, Hsu NC, Lin YF, Wang JY, Lin JW, Ko WJ
ABSTRACT: BACKGROUND: The post-discharge period is a vulnerable time for patients with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because post-discharge care continuity is easily interrupted after hospitalist care, close follow-up may decrease readmission. This study aimed to investigate the impact of a quality improvement program - integrated post-discharge transitional care (PDTC) - in Taiwan's hospitalist system. METHODS: From December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan, and discharged alive to home care were included. Quality improvement intervention in the PDTC program, including disease-specific care plan, telephone monitoring, hotline counseling, and referral to hospitalist-run clinic were performed in the latter four months in the intervention group while the control group was recruited in the first two months of the study period. The primary endpoint was unplanned readmission or death within 30 days after discharge. RESULTS: There were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics on admission and discharge. In the intervention group, 18 patients with worsening disease-specific indicators by telephone monitoring and 21 with new/worsening symptoms by hotline counseling were associated with a higher rate of unplanned readmission than those without worsening indicator (p=0.031) and symptoms (p=0.019), respectively. Those who received PDTC had lower rate of readmission and death within 30 days post-discharge than the control group (15% vs. 25%, p=0.021). Non-use of a hospitalist-run clinic and presence of underlying malignancy were other independent factors for 30-day post-discharge readmission and death. CONCLUSION: Integrated PDTC using disease-specific care, telephone monitoring, hotline counseling, and a hospitalist-run clinic can reduce post-discharge readmission and death.
PMID: 21849018 [PubMed - as supplied by publisher]