Cost-Effectiveness of a Care Transitions Program in a Multimorbid Older Adult Cohort

A mixed-methods systematic review of nurse-led interventions for people with multimorbidity

AIMS

To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them.

DESIGN

Mixed-methods systematic review following the Joanna Briggs Institute (JBI) methods for convergent-integrated reviews.

PROSPERO ID

CRD42020197956.

DATA SOURCES

Cochrane CENTRAL, CINAHL, Embase and MEDLINE were searched in October 2020. Grey literature sources included OpenGrey, the Journal of Multimorbidity and Comorbidity and reference mining.

REVIEW METHODS

English-language reports of nurse-led interventions for people with multimorbidity were included based on author consensus. Two reviewers performed independent quality appraisal using JBI tools. Data were extracted and synthesized using a pre-existing taxonomy of interventions and core outcome set.

RESULTS

Twenty studies were included, with a median summary quality score of 77.5%. Interventions were mostly case-management or transitional care interventions, with nurses in advanced practice, support to self-manage conditions, and an emphasis on continuity of care featuring frequently. Patient-centred outcomes such as quality of healthcare and health-related quality of life were mostly improved, with mixed effects on healthcare utilization, costs, mortality and other outcomes.

CONCLUSION

Interventions such as case management are agreeable to patients and transitional care interventions may have a small positive impact on healthcare utilization. Interventions include long-term patient management or short-term interventions targeted at high-risk junctures. These interventions feature nurses in advanced practice developing care plans in partnership with patients, to simplify and improve the quality of care both in the long and short-term.

IMPACT

This is the first mixed-methods review which includes all types of nurse-led interventions for multimorbidity and does not focus on specific comorbidities or elderly/frail populations. Using adapted consensus-developed frameworks for interventions and outcomes, we have identified the common features of interventions and their overall typology. We suggest these interventions are of value to patients and healthcare systems but require localization and granular evaluation of their components to maximize potential benefits.

Expansion of a House Calls Program for Patients With Dementia During COVID-19

Homebound older adults with dementia have increased health care use, hospitalization rates, and mortality risk, which are associated with considerable health care costs. A large, unmet need for individuals with dementia is home-based medical care. Although our institution has had a primary care program for homebound patients since 2019, we did not have an analogous program for patients with dementia before the coronavirus disease 2019 (COVID-19) pandemic. However, with increased health risks and challenges associated with the pandemic, we rapidly expanded the program to include facility-based older adults with dementia. We incorporated telemedicine and home-based visits to effectively provide patient-centered care that was aligned with their goals and preferences, and we describe a program example of how we provided care during a COVID-19 outbreak in a large facility. Further research is needed to capture potential cost savings and hospitalization rates for persons with dementia who receive home-based medical care. [Journal of Gerontological Nursing, 48(10), 21-25.].

Practical and measurable definitions of care coordination, care management, and case management

Integrated behavioral health is a population-based approach that acknowledges the chronic nature of most mental illnesses and the need for services beyond those delivered in face-to-face visits. These services have been referred to by different and confusing names with over 40 definitions of care coordination concepts in the literature. Kilbourne et al. in a recent article in this journal divided these tasks into three groups: care coordination, care management and case management with associated definitions provided as used in the veterans affairs system. In this commentary, while drawing on over a decade of experience in implementing care management models in the Mayo clinic system of care, I will suggest we need to be even more specific with these definitions. I propose these terms be linked to critical and measurable tasks in the management of chronic conditions, thus allowing those administrating or researching these interventions to better assess fidelity, processes and outcomes when a model is applied to a population of patients with chronic conditions in an integrated setting.

Outcomes of a Nursing Home-to-Community Care Transition Program

OBJECTIVES

Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes.

DESIGN

Propensity-matched control-intervention trial.

INTERVENTION

Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls).

SETTING AND PARTICIPANTS

Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF.

METHODS

Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use.

RESULTS

Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001).

CONCLUSIONS AND IMPLICATIONS

We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.

Adherence to care transitions recommendations among high-risk hospitalized older patients

BACKGROUND/OBJECTIVES

Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP).

DESIGN

Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older.

SETTING

A 400-bed community teaching hospital.

PARTICIPANTS

Two hundred and two patients admitted to non-ICU beds who met high-risk criteria.

INTERVENTION

Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations.

MEASUREMENTS

Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations.

RESULTS

The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups.

CONCLUSION

We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument

OBJECTIVES

Health care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients' risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients' probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model.

DESIGN

This retrospective cohort study used SNFRR scores to evaluate patient data.

SETTING AND PARTICIPANTS

The patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs.

METHODS

We compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017.

RESULTS

Mean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile.

CONCLUSIONS AND IMPLICATIONS

The SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.

Hospital to Community Transitions for Older Adults: An Update for the Practicing Clinician

Spurred by changes in both population demographics and health care reimbursement, health care providers are responding by using new models to more fully support the posthospital transition. This paper reviews common models for posthospital transition and also describes the Mayo Clinic model for care transition. Models are designed with the intent of managing the cost of health care by reducing 30-day hospital readmissions and improving management of chronic disease. Meta-analyses have proved helpful in identifying the most effective program elements designed to reduce 30-day hospital readmissions. These elements include a bundled and multidisciplinary approach to best meet the needs of patients. Successful care teams also emphasize self-empowerment for both patients and caregivers. There are 2 general types of practice. In 1 model, introduced by Mary Naylor, an advanced-practice provider cares for the patient for a set period of time, which includes home visits. In the second model, introduced by Eric Coleman, a transitions coach, who can be an RN, a social worker, or a trained volunteer, serves as the health care coach, while improving self-efficacy. Both models have been successful. At Mayo Clinic, the Mayo Clinic Care Transitions program has encompassed a 7-year experience, using the services of an advanced practice provider. In previous studies, this model demonstrated a 20.1% (95% confidence interval [CI], 15.8 to 24.1%) decrease in 30-day readmission in controls compared with 12.4% (95% CI, 8.9 to 15.7%) in the control group. Although this model was successful in reducing 30-day readmissions, there was no difference between groups at 180 days. In patients experiencing the highest deciles of cost (8th decile), enrollment in a care transitions program reduced their overall cost by $2700. This cost savings was statistically significant. Both patients and caregivers participating in the program appreciated the home visits and felt more comfortable communicating at home.

Thirty-Day Hospital Readmissions in a Care Transitions Program for High-Risk Older Adults

OBJECTIVES

To describe the causes of 30-day hospital readmissions among high-risk older adults during implementation of a multicomponent care transitions program.

DESIGN

Secondary analysis of data from the evaluation of a multicomponent care transitions program for hospitalized high-risk older adults.

SETTING

A 400-bed community teaching hospital.

PARTICIPANTS

Patients aged 75 and older admitted to non-intensive care unit beds who met specific criteria for high risk of complications and hospital readmissions. The intervention group included 202 patients, of whom 37 were readmitted to the hospital as an inpatient or on observation status within 30 days of discharge.

MEASUREMENTS

Root-cause analyses on each readmission were conducted by hospital physicians and post-acute care (PAC) organization staff. Additional data were collected by trained project staff using the medical record and postdischarge telephone or in-person follow-up visits. These data were reviewed and adjudicated among the authors, and each readmission was rated with unanimous agreement as "preventable," "possibly preventable," or "not preventable."

RESULTS

No significant differences were found in demographic and clinical characteristics of intervention patients readmitted versus those not readmitted. A higher proportion of the 37 patients who were readmitted did not have a postdischarge visit than the 165 patients who were not readmitted (15 [41%] vs 45 [27%]; P = .11). Among the 37 readmissions, 14 (38%) were rated as not preventable, 14 (38%) as possibly preventable, and 9 (24%) as preventable. Readmissions were rated as preventable or possibly preventable for a variety of reasons that provide insight into how care transitions programs for high-risk older adults might be made more effective.

CONCLUSION

Root-cause analyses of hospital readmissions among high-risk older adults by hospital physicians and PAC providers can identify strategies that might enhance the effectiveness of care transitions interventions in this complex population. J Am Geriatr Soc 68:1307-1312, 2020.