Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population
Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population
Hospital readmissions are common, costly, and potentially preventable. They are also
 potentially responsive to health system interventions. However, it is uncertain which
 components of care transition interventions are efficacious, for which populations, and at
 what cost. This randomized controlled study is part of a larger project that will evaluate a
 three-tiered quality improvement (QI) intervention intended to reduce hospital readmissions
 within 30 days post-discharge from an urban safety net hospital that serves a racially and
 linguistically diverse population (the randomized controlled study evaluates Tier 3). Few
 studies have evaluated care transition interventions to reduce readmissions among low-income,
 diverse patient populations, and the accumulated evidence on the effects of these
 multi-faceted interventions on readmission rates has been inconclusive. This project will
 take advantage of a unique sequence of three QI innovations to reduce hospital readmissions
 implemented beginning in 2007 in an integrated safety net health care system. The
 "discharge-transfer" tiers are as follows: 1) Tier 1 includes a comprehensive, individualized
 home care plan (HCP) reviewed by the medical service floor nurse with the patient prior to
 discharge; 2) Tier 2 adds the electronic transmission of the HCP to the patient's primary
 care medical home where, on the business day following discharge, a Registered Nurse makes an
 outreach telephone call to the discharged patient to confirm comprehension of the HCP and to
 address medical questions or needs; 3) Tier 3 further adds a community health worker, the
 Patient Navigator, to participate in bedside discussions to develop rapport and learn about
 patients' home situations, weekly outreach calls to assess patients' needs and to facilitate
 communication between the patient and the primary care team, and reminder calls to patients
 prior to all medical appointments to eliminate barriers to outpatient follow-up. The Aim of
 the study being registered is to evaluate the effects of an ongoing randomized natural
 experiment on readmissions, health care use, adherence to medication instructions, and
 preparedness for discharge. This natural experiment features random assignment to one of two
 QI interventions, Tier 2 or Tier 3, and exclusively targets patients at high risk for
 readmission, those with one or more of the following risk factors for readmission: discharge
 diagnosis of congestive heart failure or COPD; length of stay > 3 days; age > 60; or previous
 hospitalization within the past six months.

 The investigators hypothesize that the Patient Navigator intervention (Tier 3) compared to
 usual care (Tier 2) will increase the rates of 30-day post-discharge PCP visits; reduce
 30-day hospital readmission rates; and reduce the total number of days in hospital in the 180
 days following the index admission for high risk patients. The investigators further expect
 that the PN intervention will improve patient adherence to medication instructions in the HCP
 and reduce the probability of reported problems with post-discharge care.
Inclusion Criteria:

 -  medical patients discharged to home or skilled nursing facility between October 1,
 2011 and June 30, 2013

 -  Cambridge Health Alliance PCP at time of discharge

 -  at least one of four risk factors for readmission: discharge diagnosis of CHF or COPD;
 length of stay >3 days; age >60; or previous hospitalization within the past 6 months