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A Descriptive Analysis of the Effects Post DischargePhone Calls Have On Readmission Rates forMedicare BeneficiariesHeaven OwensRegis University

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Regis University Rueckert-Hartman College for Health Professions

Loretto Heights School of Nursing Doctor of Nursing Practice Capstone Project

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Disclaimer

A Descriptive Analysis of the Effects Post Discharge Phone Calls Have on Readmission Rates

for Medicare Beneficiaries

Heaven Owens

Submitted as Partial Fulfillment for the Doctor of Nursing Practice Degree

Regis University

December 14, 2012

Dr. Marsha Gilbert, DNP, RN & Dr. Barbara Berg, DNP, RN

i

Copyright © 2012 Heaven Owens

All rights reserved. No part of this work may be reproduced, stored in a retrieval system, or

transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or

otherwise, without the author’s prior written permission.

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Executive Summary

A Descriptive Analysis of the effects post discharge phone calls have on readmission rates for Medicare beneficiaries

Problem One in five Medicare patients is readmitted within 30 days of a previous hospitalization (Allaudeen, Vidyarthi, Maselli, Auerbach, 2011). This issue impacts patients and the healthcare system with exponential expenditures. The Centers for Medicare and Medicaid Services has mobilized recovery audits to begin recapturing funds related to readmission and reducing reimbursement for the same cause for acute healthcare facilities. Organizations must take an active role to ensure their financial integrity and protect their clinical reputation. For the purpose of this project, the population of interest was Medicare beneficiaries age 50 through 88 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF). The intervention included post discharge phone calls to patients within 72 hours of discharge. This invention was compared to current policy to analyze outcomes (reduced readmission rates).

Purpose The purpose of this project was to explore a policy which has the potential to support a reduction in readmissions without compromising standard of care.

Goal The goal of this intervention was to evaluate if post discharge patient satisfaction phone calls reduced readmissions for Medicare beneficiaries with a pathology of COPD or CHF. Objectives

The objectives of this capstone project were to: 1) identify descriptive characteristics of Medicare populations diagnosed with COPD or CHF which received a post discharge phone call and associated risk for readmission based on the LACE score; 2) determine the follow up needs of patients diagnosed with CHF or COPD post discharge; and 3) assess congruence between expected readmission and observed readmission based on the LACE tool for patients diagnosed with COPD or CHF within 0-30 days and 31-60 days respectively.

Plan The plans for this capstone include: 1) problem identification via Systematic Literature

Review (SLR) and review of local/national data; 2) identification of an analysis method and tool (LACE); and 3) evaluation of the intervention. This evaluation will be completed as a descriptive analysis of a pilot program within a Midwest teaching facility via retrospective medical record review using a convenience sample and descriptive methods which incorporate the LACE tool (Van Walraven, et. al, 2010). This project was approved by The Patient Centered Research Council at the research facility and received IRB approval from Washington University - St Louis and Regis University respectively.

Outcomes and Results

CHF patients who received a post discharge phone call experienced a decrease in readmission rates (intervention: zero readmissions vs. baseline value: 28.0%). COPD patients, however, had a readmission rate of 28.6% (compared to baseline value: 25.0%). COPD patients had a greater variation in post discharge needs compared to the CHF group. Further evaluation is warranted to understand disease specific care transition needs.

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Table of Contents

Copyright Page i

Executive Summary ii

Table of Contents iii

List of Tables iv

List of Figures v

List of Appendices vi

Problem Recognition and Definition 1

Review of Evidence 5

Project Plan and Evaluation 10

Project Findings and Results 23

Limitations/ Recommendations/ Implications for Change 31

References 33

Appendices 38

iv

List of Tables

Table 1: A Priori Power Analysis

Table 2: COPD Descriptive Statistics

Table 3: CHF Descriptive Statistics

Table 4: COPD Frequency

Table 5: CHF Frequency

v

List of Figures

Figure 1: Participant Demographics

Figure 2: Intervention by Diagnosis

Figure 3: Expected Versus Observed Readmission (By Diagnosis)

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List of Appendices

Appendix A: Systematic Review of the literature (SLR) 38

Appendix B: Logic Model 57

Appendix C: Conceptual Diagram 58

Appendix D: LACE Model 59

Appendix E: Post Discharge Phone Call/Interview Template 60

Appendix F: Data Collection Template 61

Appendix G: Data Collection Template (CHF 0-30 Days) 62

Appendix H: Data Collection Template (CHF 31-60 Days) 63

Appendix I: Data Collection Template (COPD 0-30 Days) 64

Appendix J: Data Collection Template (COPD 31-60 Days) 65

Appendix K: Timeline 66

Appendix L: Budget 67

Appendix M: IRB Approval Letter (Regis University) 68

Appendix N: IRB Approval Memo (Washington University-St. Louis) 69

Appendix O: CITI Training Completion Report 73

Appendix P: Agency Letter of Support 74

Appendix Q: SWOT Analysis 75

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A Descriptive Analysis of the Effects Post Discharge Phone Calls Have on Readmission Rates

for Medicare Beneficiaries

There are many traits that can place a person into a vulnerable category. The Centers for

Disease Control and Prevention ([CDC], 2010) defined vulnerability based on racial and ethnic

minority, disability, age, gender, geography, and socio-economic status. In addressing discharge

needs from hospital to home, hospitals must look to reduce length of stay, prevent readmission,

and facilitate the transition for the patient and family. As acute care facilities across the country

strive to meet the complex needs of these groups, readmissions have became a compounding

factor. Increased attention has been given to readmission on a local and national level. Effective

risk mitigation strategies are key for optimal patient outcomes.

Problem Recognition and Definition

One in five Medicare patients was readmitted within 30 days (Allaudeen, et. al., 2011).

The cost estimate for 30 days readmissions was $17.4 billion (Foster & Harkness, 2010).

Analyses of hospital readmission data at state and local levels could be linked to quality, psycho-

social, and access issues (Bhalla & Kalkut, 2009). Medicare beneficiaries were at substantial

risk for readmission and constitute a vulnerable population related to eligibility criteria including

factors such as age (65+), chronic illness, or disability. For older populations, vulnerability was

secondary to their frail nature and need for resources on discharge (Bauer, Firtgerald, Haesler, &

Manfrin, 2009). Patients age 75 years and older, male, and African American were

independently associated with higher risk of 30-day hospital readmission (Silverstein, Qin,

Mercer, Fong, & Haydar, 2008).

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Readmissions can have serious implications for patients and facilities. The post

discharge phone call was viewed as an opportunity to address any patient needs post discharge,

answer questions, and inquire on follow- up and adherence to discharge plan. In 2010, the study

facility implemented post discharge phone calls. These phone calls were made to patients

discharged from specific nursing units by a designated Registered Nurse (RN) within 72 hours

post discharge. The phone call was initially targeted to improve patient satisfaction scores.

Evidence contends that this call may have the opportunity to decrease readmission as well

(Boulding, Glickman, Manary, Schulman, & Staelin, 2011). “Tahan recommends making post-

hospital discharge calls within 72 hours to make sure the patient has filled his or her prescription,

understands what medications to take and when, and confirm that the patient had a follow-up

appointment in place (Hospital Case Management, 2010, p. 22). Timely discharge follow-up by

telephone to supplement standard care was effective at reducing near-term hospital readmissions

(Harrison, Hara, Pope, Young & Rula, 2011).

As a transformational leader, the Doctor of Nursing Practice (DNP) promotes practice

excellence, compliance, and optimal patient outcomes. For this project, a quality analysis

approach has been taken to evaluate the effectiveness of this phone call in preventing

readmission. The population of interest was Medicare beneficiaries age 50 through 88 with a

primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart

Failure (CHF). The intervention included evaluation of previously completed post discharge

patient satisfaction phone calls to patients/caregivers within 72 hours of discharge. This

intervention was compared to baseline data for usual care per existing organizational policy to

evaluate outcomes (reduced readmission rates).

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The PICO question for this capstone: In Medicare patients between the ages of 50-88,

will a follow-up telephone call within 72 hours following discharge from an inpatient hospital

experience reduce readmission rates within 30 days for clients diagnosed with Chronic

Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) compared to usual

care? The proposed outcome was reduced readmissions to the hospital based on an enhanced

discharge process from the hospital which incorporated a post discharge phone call. This

systematic evaluation occurred at the organizational level. There were multifaceted implications

for patients, nurses (direct care and case management), and interdisciplinary teams.

There must be a balance between cost and quality for healthcare organizations to sustain

and support the best interest of patients who are served. The DNP role is integral in assisting

organizations toward best practice models. In the context of this project, change management

was paired with nursing theory throughout this intervention and analysis of patient care at the

facility. The Transtheoretical Model of Behavior Change assessed an individual's readiness to act

on a new healthier behavior, and provided strategies, or processes, of change to guide the

individual through the stages of change to action and maintenance (Cheung et al., 2007). The

nurse case manager could support the patient’s transition through the stages. These stages

included precontemplation, contemplation, preparation, action, maintenance, and termination.

This theory provides a basic assumption for patients moving though the healthcare system in the

acute setting. At the time of the hospital admission, the patient was in the precontemplation

stage. There was no intention of taking a specific action toward behavior change in the next six

months. The patient may not be aware of the need for change or may be aware, but has

neglected to adhere. It is important to note that non -adherence may be the result of external

factors. During hospitalization, the patient moved into contemplation and recognized need for

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change. Self reflection and education occurred during this time. During discharge planning, the

patient moved into preparation. This movement is based on dialogue with physician, RN,

ancillary teams, and the nurse case manager. The patient gained understanding that they can try

to avoid being readmitted. The patient developed intent to act within the next 30 days. The case

manager assisted with development of a discharge action plan. The patient actively participated

in the planning process. Post discharge, the patient moved into the action phase and adhered to

follow-up regimen as ordered. This was supported by post discharge interventions including

follow-up phone calls and outpatient case management. The patient worked with healthcare

teams to prevent readmission. Maintenance moved the patient through continued compliance and

adherence to discharge regimen. With successful outpatient management, the phases reached

termination based on self efficacy for the patient who was on a healthy track for avoiding

previously used methods for coping with illness and preventing associated readmission.

Literature has been reviewed and produced multiple interventions and the issue of

readmissions. Case management teams and transition care planning represented best practice

models across the country. Scholarly publications across healthcare disciplines recognized the

importance of this critical issue. Comprehensive discharge planning and interventions for

elderly populations must be sensitive to their vulnerabilities. Case managers have proven to be

vital in facilitating this transition and reducing readmission (Ahmed & Rak, 2010). Case

management teams serve as a resource for patients and a bridge for interdisciplinary

collaboration. Transitional case management facilitates the transition from hospital to home.

As readmission rates were identified, hospital based case managers were increasingly responsible

for interventions which decreased readmission.

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Review of Evidence

Background of the Problem

Readmission can reflect poor quality healthcare and has been found to substantially

increase Medicare expenditures (Averill et al., 2009). As of March 2010, Congress passed the

Patient Protection and Affordable Care Act (PPACA). “With passage of this act, Congress gave

Centers for Medicare and Medicaid Services (CMS) the authority to penalize hospitals for excess

readmission rates starting federal fiscal year 2013” (Foster & Harkness, 2010). This made

healthcare providers increasingly responsible for managing healthcare expenditures. Initial

efforts focused on heart failure, acute myocardial infarction, and pneumonia. This data was

examined on the CMS website as a hospital quality measure. When comparing hospital outcome

of care measures for patients of the study site, the rate of readmission for heart attack patients,

heart failure patients, and pneumonia were higher than that of national standards. Specifically,

the national readmission rates have been identified as 19.9% for heart attack compared with the

hospitals rate of 22.6% (U.S. Department of Health and Human Services, 2011). The U.S.

national average for 30 days for heart failure readmission is 24.8 % compared to a hospital value

of 28.0% while the pneumonia readmission average for the hospital is 22.3% compared to

18.3% on a national level (U.S. Department of Health and Human Services, 2011). There are

also plans to extend such programs. “Beginning in 2015, CMS may also begin withholding

payments for excessive readmissions related to chronic obstructive pulmonary disease (COPD),

coronary artery bypass grafts (CABG), percutaneous coronary interventions (PCI), and some

vascular surgery procedures” (Foster and Harkness, 2010). The Center for Medicare and

Medicaid Services (CMS) COPD benchmark was currently in development. The hospital’s

readmission rate for COPD was 25%.

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CMS has already implemented enforcement measures to recover funds where medical

necessity is concerned via The Recovery Audit Contractors (RACs). RACs have been mobilized

to detect and correct improper payments. As a major payer source, this funding was an integral

part of the healthcare organization's operating budget. A decrease in funding from this source

could be detrimental to the facility. The Case Management department at the research site was

charged with developing and implementing risk mitigation strategies.

Systematic Review of the Literature

Systematic Literature Review (SLR) included search of databases including Medline,

Academic Search Premier, CINAHL, Google Scholar, PubMed, and Wiley Online Library. Key

search terms used were readmission, discharge planning, discharge medication reconciliation,

and case management as well as the paired terms case management and readmission. This

search yielded multiple levels of evidence from I to IV. The evidence is categorized from the

highest form of evidence (Level 1) to the lower levels which included Levels III, IV, VII (Houser

& Oman, 2011). More than eighty articles were reviewed, thirty of which were subsequently

included in the systematic review of evidence table (Appendix A). For the purposes of this

capstone, only Levels I-III were included. Articles were selected based on subject matter,

content, and congruency with the purpose of this capstone. Each article has been carefully

analyzed for strengths/weaknesses, levels of evidence, the study aim/purpose, methods, outcome

measure, and the author’s conclusion to aid in developing this capstone. The findings of the SLR

provide integral information pertaining to patients’ perceptions, at risk groups, the benefits of

telephone follow up, and interdisciplinary elements of care transitions.

Literature suggested that the role of the case manager was integral to discharge planning.

This role was generally performed by an RN who was knowledgeable in Medicare guidelines,

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patient assessment, community resources, and interdisciplinary communication. This RN

collaborated with patients/families, direct care RN’s, and across disciplines to ensure optimal

patient outcomes. When indicated, the case manager generated appropriate referrals to promote

continuity of care via home care RN, Physical/Occupational therapy, and other support staff to

maintain wellness post discharge.

The Logic Model (Appendix B) was instrumental to understanding resources, program

activities, outputs, outcomes, and impacts of the project. Key resources that have been identified

included staff nurses, nurse case managers, case management leadership, pharmacy, home

health, and community based /hospital-based providers. Each had a distinct role in facilitating

program activities. When these activities were performed, they produced useful outputs. The

outputs were transformed into viable patient outcomes which yielded short and long term

impacts. The primary impact of concern was reduced hospital readmission.

Theoretical Framework

The conceptual diagram (Appendix C) features three major concepts which were

evaluated by the capstone project: 1) patient health; 2) post discharge follow up; and 3) hospital

readmission. This model merged multiple theories in a specific context (Earp & Ennett, 1991).

Consistent with Betty Neuman’s System Model, health was defined as wellness versus illness

(Neuman & Reed, 2007). With the aging population (50+), there may be a new onset of acute

illness or the exacerbation of chronic health issues. In the model, the patient’s health, perception

of this disharmony, and their understanding of self care regimen were contributing factors to

hospitalization. Once in the hospital, Neuman’s primary prevention measures have failed; the

effort was shifted toward retaining stability (Secondary Prevention). While moving through the

health continuum, the patient’s health status and discharge readiness were modifying factors that

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affect the hospital discharge. Discharge readiness was composed of both objective and subjective

findings based on feedback from the patient and family. The discharge process itself was

facilitated by interdisciplinary collaboration. The standard discharge process assessed the

patient’s support system and identified deficits. While hospitalized (tertiary prevention),

community referrals were made to assist with identified self-care deficits, which is consistent

with Orem’s Self Care Deficit Theory (Fawcett, 2003). These referrals along with the patient’s

support system were integral to appropriate follow up. The intervention provided enhanced

patient collaboration for an increasingly supported transition via the post discharge phone call.

After discharge, efforts were shifted maintaining stability which was acquired during the

hospitalization. Various technologies, information or processes used to attain desired results,

were employed to reach the patient. Home health services, ongoing PCP communication,

medication reconciliation, regimen adherence, and patient follow up were key considerations

post discharge. The post discharge phone call assisted in closing the gap between hospital and

home (post discharge follow-up). Omission of variables while moving along the continuum or

break(s) in continuity contributed to hospital readmission. Follow up phone calls served as a

bridge to close the communication gap post discharge to ensure that all post discharge

expectations were fulfilled (Fawcett, 2003).

The Transtheoretical Change Model (TTM) has been paired with nursing models per

demonstrated ability in studies of behavior change in older adults to promote increased physical

activity. Higher stages were positively associated with physical activity and physical function

(Riebe et al., 2005). Similar to this intervention, Kolt, Schofield, Kerse, Garrett, and Oliver

(2007) utilized phone calls (counseling) with the intent of evaluating long term effectiveness of

the telephone intervention on physical activity. Participants included 186 low-active adults (age

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65+) recruited from their primary care physicians’ patient databases. Each received phone calls

over 12 weeks. The outcome demonstrated a positive impact of increasing physical activity over

a 12- month period. Cheung et al. (2007) used multiple modalities of phone calls combined with

home visits to obtain similar results. This study included 86 participants age 55 and older,

independent, ambulatory (30 feet without stopping), and a Mini Mental State Examination score

greater than 23. The seven day activity recall questionnaire was paired with the exercise

decisional balance tool. T-tests were used to evaluate adopters versus non-adopters. At follow-

up, participants were assigned into three groups: precontemplation, contemplation, or

preparation. Changes were lower in the contemplation group and higher in the regular exercise

group. Research by Kim, Cardinal, and Lee (2006) offered internal and external validation for

health behavior change using TTM.

Careful evaluation of proposed interventions promoted optimal outcomes for patients.

Post discharge telephone calls identified important opportunities for intervention and may even

prevent future problems (Dudas, Bookwalter, Kerr, & Pantilat, 2002). Talking to people shortly

after discharge gave them time to formulate their thoughts and questions (Handley, 2009). New

Hanover Regional Medical Center has experienced success with a CHF disease management

program that included an outpatient telephonic program. The program has been cited as

extremely successful in meeting patient-focused and organizational goals related to

readmissions, length of stay, and cost of care (Slater, Phillips, & Woodard, 2008). To a similar

end, Harrison et al., (2011) implemented a study to evaluate the impacts of telephonic outreach

focused on adherence to discharge orders and subsequent readmission within 30 days. Patients

were evaluated for readmission following receipt of post discharge phone call using multiple

logistic regression and adjustment of covariates. Older age, male sex, and increased initial length

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of stay (LOS) were associated with increased readmission . The post discharge call was

associated with reduced rates of readmission. This group was less likely than the comparison

group to be readmitted within 30 days of hospital discharge .

Retrospective cohort studies by Ahmed & Rak (2010) examined the relationship between

participation in a large wellness and care management company’s transitional case management

(TCM) program and hospital readmission. Data was analyzed for the 10,258 participants using

multivariable logistic regression. Readmission predictors included TCM care management

engagement, length of stay for the initial hospitalization, cost of initial inpatient stay, risk score,

age, and sex. Readmission rates were lower for case management group compared to the control;

fewer participants from the TCM group were readmitted to the hospital compared with those not

participating. In the first 30 days, non participants in TCM were almost 4 times more likely to

have a hospital readmission.

Project Plan and Evaluation

Market & Risk Analysis

COPD is a cluster of diseases that interfere with airflow and cause breathing problems.

This can include emphysema, asthma, or chronic bronchitis. Factors such as pollutants, genetics,

and respiratory infections were also associated with COPD (Centers for Disease Control and

Prevention, 2011). Smoking plays a key role in disease development and progression. In St.

Louis, 19% of seniors reported smoking in 2007 (University of Missouri, 2010). COPD

contributed to an annual rate of 19.1 local hospitalizations between 2005-2009 (Missouri

Department of Health and Senior Services, 2011b). Associated factors included the COPD

related death rate, which was 37.1 locally and 46.91 statewide. Likewise, CHF had strong

implications for this population. CHF was the leading cause of hospitalization in older adults.

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CHF contributed to a rate of 51.6 local hospitalizations between 2005-2009 and 35.8 statewide

for Missouri (Missouri Department of Health and Senior Services, 2011a). African-Americans

were noted to have the highest incidence rate of CHF, followed by Hispanic, white, and Chinese

American (Bahrami et al., 2008). Given the aforementioned readmission rates for COPD and

CHF respectively, there was a need to analyze both further in order to prevent readmission. A

primary concern for hospitalized patients was the question of “What happens next?” Patients

were sheltered within the confines of the hospital, but when they leave, what steps do they need

to take? Some patients and families may be overconfident until the details regarding discharge

begin to unfold because the hospital was a safe environment equipped with medical teams for

support. The uncertainty became apparent during teach-back or within the context of discussion

with the healthcare team. Patients with a knowledgeable support system (average to high level

healthcare literacy) were better prepared to navigate the healthcare system as long as all of the

details were on paper. Those who lacked the needed resources have a gap which needs to be

closed. As federal and other regulatory guidelines evolve to ensure safe, cost- efficient, and

quality care, facilities must develop proactive strategies to address the needs related to these

areas and reduce readmission.

Strengths, Weaknesses, Opportunities & Threats

From an organization standpoint, Ross, O'Tuathail, and Stubberfield (2005) proposed that

early identification of potential barriers and setbacks to implementation enabled the intervention

to be appropriately tailored and supported with the result that there were positive patient, staff

and organizational outcomes and change. In order to proactively prepare for the project,

strengths, weaknesses, opportunities, and threats were carefully evaluated. In terms of strengths,

the capstone was patient centered and served to promote optimal outcomes for patients. It also

12

had a benefit to the facility and community by ensuring appropriate utilization of hospital

resources by decreasing unnecessary and preventable readmission. In reducing readmission, the

hospital facilitates throughput and promotes cost effective utilization patterns. This promoted

optimal outcomes for patients and reduces financial liability for the facility. The capstone was

reviewed by multiple committees within the academic/hospital setting and had the support of

case management leadership at the facility. Along with leadership support, the facility

understood the issue at hand and the implications for the organization. Readmission rates had

become a corporate initiative and each community hospitals in the system was tasked with

developing effective interventions as a counter measure. The Principal Investigator’s (PI) skills

and background were an optimal choice to conduct sole case reviews. The PI was a master’s

prepared DNP candidate RN, which had a professional background in case

management/utilization review combined with clinical nursing experience, and the case

management supervisor at the study site. In terms of weakness, the PI had limited access to

readmission data for hospitals outside of the study facility’s healthcare system. Thus, the PI was

only able to assess readmissions within 30 days on a limited basis. In all actuality, the patient

may have been readmitted at an alternate facility which may have represented a shift or loss of

data. Due to the retrospective nature of the study, the PI only had access to documented data at

the study site. There ass no opportunity to inquire for additional clinical information as in real

time. The PI relied on the presence of clinical data in the electronic database. The PI was forced

to omit patients who did not have adequate data in the electronic health record. This capstone

had inherit weakness as it focused on groups through age 88 with two particular diagnoses. The

opportunity existed for expansion of diagnosis groups and age groups. Unintended opportunities

included a decreased in length of stay and increased patient satisfaction. As the Center for

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Medicare and Medicaid Services (CMS) guidelines continued to develop, the scope of such

interventions may expand. A key threat to this research was the validity. To counter this threat,

the PI aimed for optimal statistical power analysis including a sufficient sample (Kane &

Radosevich, 2011). Careful attention was been given to this area to ensure the appropriate level

of analysis.

Driving/Restraining Forces

CMS initiatives and increased awareness of the implications of care transitions for

patients were driving factors for this capstone. Like many facilities around the country, the study

site was committed to excellence in patient care. This not only included bedside care, but also

encompassed transitions from the acute care setting to alternate levels of care. Outcomes of this

study had the potential to develop a working framework for future interventions with this

vulnerable population. Patient care was a primary concern. The hospital was at risk for financial

loss and negative reporting if it failed to address this issue. Without financial resources, the

hospital was at substantial risk of impact to patient care services. Human resources were a

restraining factor for this capstone. Due to the retrospective nature of the study, the staff

involved were not dedicated full time staff members who had been solicited for the sole purpose

of the capstone; rather, they were hospital team members who had primary roles and participated

in capstone components as secondary roles. This intervention provided insight into nurse case

management staffing needs in order to conduct such follow up on an ongoing basis. A full time

case management department was in place at the facility. Resources would need to be allocated

to this area for sustainability of such programs long term. These resources included full time

staff, workstations, and training. The volume of patients determined the number of staff needed.

The average daily census of the facility was 900. With an average of 300 discharges per day, the

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estimated need was 15 dedicated case managers to conduct post discharge phone calls for

sustainability. This was based on the assumption that each call is approximately 15 to 20

minutes including necessary follow up for an eight hour work day. Due to the hospital volume,

this capstone focused on discharges from one inpatient unit in the hospital. This factor

increased feasibility of the capstone and allowed for streamlined efforts with a designated nurse

making the post discharge phone calls to patients on this unit. Risks associated with a single

nurse working on the intervention included scheduling conflicts, time constraints, facilitation of

follow up needs, and discharge volume on high turnover days. Unintended consequences of the

capstone included the opportunity to reveal process gaps in current discharge planning on

various levels from physician communication, nursing documentation, and case management

follow through. There was also the potential for increased communication breakdown by adding

an additional person to the interdisciplinary team and primary communication via telephone.

The post discharge phone calls were initially aimed at increasing patient satisfaction scores for

the nursing unit. This capstone was using the same data which was collected to assess for the

potential to prevent readmission; therefore, there was an inherent risk for missing data elements.

With the evolving CMS guidelines and technology at the facility, there was the constant potential

of being behind the change curve.

Key Stakeholders

Key stakeholders included patients, families, staff of the institution, and the community.

Failure to address healthcare waste created trickle down affects for the community at large.

When a patient was readmitted without appropriate medical necessity, hospital throughput was

jeopardized. The patient utilized bed and staff resources that could have been allocated to meet

the needs of a new patient with medically indicated acute care needs. The facility received

15

reduced (or denied) remuneration for the admission which impacted the bottom line. This in turn

impacted the available budget for operational needs. The patients were placed at increased risk

for compounded co-pays, polypharmacy, and healthcare acquired illness. Rehospitalization also

created caregiver role strain for concerned families who waited at the bedside for answers.

Cost/Benefit Analysis

The PI was the sole project team member for evaluation of the post discharge phone calls

for this capstone. The PI required a significant number of hours to personally analyze chart data

including analysis of supplemental phone call data (Appendix E –Appendix J). If chart review

and analysis were conducted by a third party at an estimated rate of $34.50 per hour, estimated

cost for man hours are $3,450 based on 100 hours. It was not feasible to calculate the RN hours

for the phone calls due to the retrospective nature of the study. A one day adjusted stay could

equal roughly $2,000. By evaluating the impact of the discharge phone calls, the 100 hour

investment might be offset by preventing a one day readmission for two patients. The cost

savings was more substantial when multiplied by seven (study intervention number) for an

estimated total of $28,000 for both diagnoses combined.

Mission/Vision

The mission and vision of the research supported the underpinnings of the institution. The

vision of the capstone was to provide a sound quality analysis measure of evidence-based

interventions within the study site to promote reduction in Medicare readmissions to 10% for

diagnosis of COPD and CHF by 2013. The capstone mission was to descriptively quantify use of

post discharge phone calls initially intended for the purpose of patient satisfaction as a method to

prevent readmission and evaluate use of the LACE index (Appendix D) to identify patients at

16

risk for readmission within 30 and 60 days respectively for patients diagnosed with COPD or

CHF (Van Walraven et al., 2010).

In order to promote this mission and vision, the capstone objectives were to be met by

April 15, 2012. The objectives of this capstone project were to: 1) identify descriptive

characteristics of Medicare populations diagnosed with COPD or CHF which received a post

discharge phone call and associated risk for readmission based on the LACE score; 2) determine

the follow up needs of patients diagnosed with CHF or COPD post discharge; and 3) assess

congruence between expected readmission and observed readmission based on the LACE score

for patients diagnosed with COPD or CHF at zero to 30 days and 31to 60 days respectively.

Incremental goals assisted in keeping the plan on target while moving toward the

overarching goal (Appendix K). To conduct a thorough evaluation, the PI required access to the

database used to track post discharge phone calls by the unit based RN, the electronic health

record, Excel tracking form for confidential data entry, and the LACE tool. The capstone

workstation resources included computer, access to relevant clinical and data processing

applications, and SPSS for data analysis. The total project had an estimated cost of $7160. The

PI had incurred $110 in expenses to cover access to SPSS v.20 while the facility had offset

$3600 via provision/access to facility resources for the capstone. As the sole reviewer, the PI

was able to eliminate the $3,450 cost for an additional nurse reviewer. No external funding was

received for this study (Appendix L).

Initial IRB approval was obtained from Regis University on October 26, 2011 (Appendix

M). Facility approval was provided by The Patient Centered Research council on December 15,

2011. Following this approval, contact was established with nurse manager on the affiliated

floor to discuss feasibility of retrospective research involving the discharge phone call database.

17

Immediate verbal commitment was received. The PI obtained study approval for retrospective

evaluation of discharge phone calls on February 15, 2012, from Washington University

(Appendix N). Candidates for the study were screened for the inclusion criteria between

February 18, 2012, and February 26, 2012. Research participants were screened based on age (50

to 88 years), diagnosis (COPD or CHF), primary insurance (Medicare), and final discharge

disposition (home or assisted living). Patients who were discharged to a skilled nursing facility

or inpatient rehabilitation were excluded. As of March 2012, The PI extracted data to meet the

needs of the study by established resources for clinical information (electronic medical record

[EMR]: Compass and Clindesk).

This study was conducted based on a pilot practice in an acute care hospital setting as a

retrospective repeated measures descriptive medical record review using a convenience sample.

The retrospective method allowed the PI to control for diagnosis and receipt of the post

discharge phone call. Due to the nature of the study, it was impossible to forecast the exact

timeframe of readmission in a prospective manner (excluding scheduled readmission).

Retrospective review allowed for identification of readmitted patients within a given time frame

(30 and 60 days respectively). Chart reviews provided a relatively inexpensive ability to research

rich, readily accessible existing data, and to generate an hypotheses that then could be tested

prospectively (Gearing, Mian, Barber, & Ickowicz, 2006). Convenience sampling was noted as

the least costly and facilitates access and accessibility to subjects (Marshall, 1996). Repeated

measures methodology allows for higher validity and decreased variability in smaller groups.

The Logic Model

The Logic Model (Appendix B) provided a retrospective review of program activities and

stakeholders (direct and indirect) that worked together to yield the end result. While there are

18

many ancillary outcomes, the primary focus of this capstone was readmission. The direct care

RN teams reviewed discharge orders with patients, provided discharge education, and addressed

questions regarding discharge as standard care. The intended outcome of this activity was

patient knowledge of the discharge orders and working knowledge of the discharge plan. This

understanding aided in post discharge adherence to plan as instructed. As standard care, the

hospital-based case management team interviewed every patient as part of the case management

assessment. This team was responsible for collaboration and community referral to facilitate

planned discharge. Dialogue with the interdisciplinary team, the patient, and community

referrals yielded effective care transitions. With the dedicated direct care RN on the floor

conducting the post discharge phone call, there was a hand-off from hospital to home.

Implementation of an outpatient case manager in the future may warrant the RN case manager to

perform the post discharge component. Short term impacts for nurses and case managers

included patient satisfaction on discharge and reduced readmission. Long term impacts

improved nursing resource allocation and sustainable outpatient management for patients.

Case management leadership provided support for the project and access to the data.

Capstone outcomes provided measures for future patient care and transition management. This

increased awareness of system issues and patient needs regarding discharge planning. Short term

impacts for case management leadership included reduced readmission and streamlined patient

throughput. Long term outcomes were consistent with CMS compliance, hospital

decompression, and improved resource allocation. Case management leadership worked to

cultivate the working relationships with the pharmacy. The pharmacy was integral to supporting

the staff nurses and case management teams via collaboration and education where medication

was concerned (Layson-Wolf & Morgan, 2008). This relationship assisted with removing

19

barriers to obtaining medications as needed, addressing medication inquiries and assisting to

resolve discrepancies. This support has the potential to yield higher adherence rates and access

to medication (Kripalani, Henderson, Jacobson, & Vaccarino, 2008). Short term impacts were

increased patient satisfaction, reduced wait time for medications, reduced risk for polypharmacy,

and reduced readmission.

While the patient was admitted, there was ongoing interdisciplinary collaboration

regarding the patient’s discharge needs. Physician and affiliated Nurse practitioners provided

orders to initiate the discharge care plan. Consistent communication with case management and

staff RNs as well as outpatient providers as needed facilitated increased patient and provider

satisfaction, increased compliance with follow up, and reduced readmission. Collaboration with

community based outpatient service providers facilitated the connection of patients to outpatient

resources and management. This yielded long term reduction in readmission and improved

healthcare utilization patterns.

Population and Sampling Parameters

Table 1: A Priori Power Analysis

F tests - ANOVA: Repeated measures, within factors

Effect size f 0.2500000

α err prob 0.05

Power (1-β err prob) 0.95

Number of groups 2

Number of measurements 4

Corr among rep measures 0.5

Nonsphericity correction ε 1

20

For sufficient power analysis, the minimal sample size was determined to be 36 using G

Power 3.1 (Erdfelder, Faul, & Buchner, 1996). This N of 36 was multiplied by four for a total of

144 participants. The target sample size for each diagnosis was calculated to be 72 (see Table 1).

The 36 participants from each diagnosis would be assessed twice for a total of 144

measurements. Of 327 patients who received a post discharge phone call, 14 patients met the

inclusion criteria, therefore the target N was not achieved. Seven patients were categorized to

the COPD group and the remaining seven met CHF criteria based on past medial history and

diagnosis for a total N of 28.

All patients included in the convenience sample were discharged from the same nursing

unit to reduce risk of practice variation in terms of delivery and content of the follow up phone

calls. A repeated measures design was used to evaluate the same group of patients. The

independent variable was documented follow-up phone calls completed by an RN within 72

hours to a Medicare patient age 50 -88 discharged from the hospital with a primary diagnosis of

COPD or CHF. The dependent variable was the number of documented readmissions with the

same original diagnosis (COPD or CHF) within 30 and 60 days of the index discharge. Standard

nursing care at time of discharge provided patients with two copies of their discharge instructions

accompanied by medication reconciliation, and prescriptions as indicated. As a standard of care

for all patients, the direct care RN reviewed the discharge materials with the patient and the

patient signs a third copy which was placed in the permanent record to confirm receipt of the

information.

The RN who conducted the phone calls had specific knowledge of this population

secondary to a direct patient care role of caring for patients with cardiac and pulmonary disease.

This RN had also specific knowledge related to signs and symptoms and disease management

21

measures. The post discharge phone calls were documented on a supplemental database that is

retained by the nursing manager on the unit. The RN Call Back Interview Template was

designed to promote consistency in phone calls. Interview items included the major categories

of empathy and concern, clinical outcomes/discharge, service, process improvement, reward and

recognition, and appreciation (Appendix E). Clinical outcomes and discharge elements are

supported by Tahan’s assertions including verification that medications were filled, follow up

appointment was made, pain and comfort level were assessed, and discharge instructions and the

discharge process were understood (Hospital Case Management, 2010). The nurse was

empowered to respond to patients’ inquiries within the nursing scope of practice and address

appointment concerns.

Protection of Human Rights Procedure

To facilitate approval for this capstone, The PI completed dual Collaborative Institutional

Training Initiative (CITI) for Regis University and the study site. Subsequent review by Regis

University Institutional Review Board (IRB), the IRB of record for the facility, and the Hospital

Department of Research for Patient Care Services provided approval to proceed with the study as

designed. Accordingly, all The Health Insurance Portability and Accountability Act of 1996

(HIPAA) and organizational regulations were followed and strictly enforced during all chart

reviews and documentation of data. When compiling data, clinical elements were extracted from

the chart while excluding any identifying elements. Any identifying information was omitted for

data collection purposes. No master copies of the log were retained to protect the privacy of

patients. Information was stored on the private computer H-drive within the secure hospital

network. The computer which the PI utilized was secure and password protected on the network

maintained by the facility. The computer itself was housed in an office which was locked when

22

unattended by the PI. No paper documents were retained by the PI. All Chart reviews occurred

electronically over secure facility network. No identifying information was entered into the

electronic worksheets. All chart reviews were conducted electronically with careful attention to

the essential elements and nothing additional. No identifiers existed in conjunction with during

data collection. These identifiers were in no way transcribed during data collection source or

other temporary location during data collection.

Data Collection

In addition to the information accessed in the electronic medical record, the PI obtained

access to the discharge phone call log which is maintained by the nursing manager on the secure

network. This tool had been developed as a culmination of various evidenced-based resources

and has not been evaluated for validity. The PI extracted information related to the receipt of a

discharge phone call and patient’s follow- up needs that were ascertained and addressed during

the phone call. The LACE index (Appendix D) evaluated: L, length of stay; A, acuity of

admission; C, patient comorbidity; and E, number of visits to the emergency room. This tool

could be used to quantify risk of death or unplanned readmission within 30 days after discharge

from hospital. The LACE index had a potential score ranging from zero to 19 with corresponding

percentage of readmission within 30 days or death noted at 2.0% to 43.7%. The LACE score

greater than or equal to 11 indicated high risk for readmission. This tool has been validated with

a 95% confidence interval (Van Walraven, Dhalla, Bell, Etchells, & Forster, 2010). Use of the

LACE tool allowed the PI to evaluate the patient’s identified risk for readmission in connection

with the prevention efforts introduced via the post discharge phone call. In addition to elements

of the discharge follow up phone call, each participant was evaluated for their LACE score at the

time of the index admission and at day 31 from discharge. Participants were further evaluated

23

for select descriptive variables including age, race, gender, services received as a follow-up to

the post discharge phone call and readmission between zero to 30 days and 31 to 60 days.

review data collection occurred between March 3, 2012, and March 10, 2012. The convenience

sample of 14 discharged to home in-patients’ charts was reviewed for documentation of a post

discharge follow-up phone call, LACE Scores, and documentation of any readmission

occurrence for the same diagnosed pathology within 30 days of discharge between March 1,

2011 and September 1, 2011. As indicated in the literature review, these diagnoses were of

particular interest due to the nature of readmissions for this vulnerable population. The PI

reviewed the post discharge phone call logs to obtain information related to the phone call

including the date and follow up needs of the phone. Using the EMR, the patient’s pertinent

hospital information was accessed by the PI. For the purpose of this study, CHF and COPD

groups were evaluated independently. Additional data collected included descriptive

measurement of patient level variables.

Project Findings and Results

Subjects were evaluated via descriptive methods with respect to their LACE score,

presence of readmission, and other descriptive characteristics of age, race, and diagnosis, and a

documented intervention which occurred as a result of the follow-up phone call (Appendix G and

Appendix H). The same patients were reevaluated for readmission between 31 and 60 days post

discharge (Appendix I and Appendix J). The LACE score was applied at day 31 post discharge

for all patients. The PI used Statistical Package for the Social Sciences (SPSS) Version 20 to run

statistical analysis: range (minimum and maximum); mean; standard deviation; variance;

skewness; and kurtosis for patients’ ages, dual LACE scores, and number of readmissions

between zero to 30 and 31 to60 days of discharge (Table 2 and Table 3).

24

Table 2: COPD Descriptive Statistics

Table 3: CHF Descriptive Statistics

Frequency tables were developed via the SPSS product for age at the time of admit,

patient’s gender, the number of readmissions within 30 days and 31to 60 days respectively, dual

LACE score, and lastly the services received in association with the follow up phone call. Cross

tabulation was used to evaluate LACE scores (Day zero and day 31) and the relationships to the

observed readmissions. Patients with COPD were evaluated independently of those with CHF as

anticipated. One Way repeated Measures ANOVA were applied to LACE score for the index

25

admission and the follow up measurement for day 31 post discharge. No participants were

missing data.

Table 4: COPD Frequency

The first objective was to identify descriptive characteristics of Medicare populations

diagnosed with COPD or CHF which received a post discharge phone call and associated risk for

readmission. The age of the COPD participants ranged between 63 and 78 years (mean 71.57,

SD 5.9.), and 71.4% (N=5) of were female. Patients ages 61 to 70 comprised 42.9% (N=3) of

the group with the remaining 57.1% (N=4) between ages 71 to 80 (Table 4). The percentage of

African American participants equaled 71.4% (N=5) while 28.6% (N=2) were Caucasian. The

26

LACE index score on admission (mean 9.00, SD 1.8) did not vary significantly from the LACE

index score at 31 days (mean 9.86; SD 1.8). For the COPD group, the patients’ age correlated to

readmission between 0-30 days with a significance of .445 and between 31- 60 days at a

significance of .179 (Both >p.05). Similarly, race and gender were also found to be

insignificant in this subgroup at 0.257 for the first 30 days and 0.288 for 31-60 days.

Readmission correlation was tested using one-tailed Pearson’s Correlation coefficient to

determine significance. There were no significant findings for gender, race, or LACE score in

terms of readmission.

Table 5: CHF Frequency

27

The age of the CHF participants ranged between 56 and 88 years (mean 77.8, SD 11.3),

and 71.4% (N=5) were male. Patients ages 50-60 comprised 14.3% (N=1); 28.6% (N=2) were

between the ages of 71to 80; and 57.1% (N=4) were between 81and 88. The percentage of

African American participants equaled 57.1% (N=4) while 42.9% (N=3) were Caucasian (Table

5). The LACE index score on admission (mean 9.71, SD 3.039) did not vary significantly from

the LACE index score at 31 days (mean 10.71; SD 3.039).

Figure 1: Participant Demographics

There was greater age variation amongst the CHF participants which also had the potential

to represent a variation in functional status (activities of daily living, self care, etc.), level of

independence, and disease progression. African American participants represented a greater

portion of both diagnoses. The ratio for COPD was 2.50 to one, while CHF was 1.33 to one

(Figure 1). Inverse relationships were noted between the two diagnoses with 71.4% (N=5) being

female in the COPD group and the same number representing the male participants in the CHF

group. “Blacks and Hispanics receive significantly disparate care at high expenditure levels,

61-70

50-60

Female

Male

African American

African American

81-88

Female

CaucasianCaucasian

71-80

71-80

Male

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Age- COPD Age-CHF Gender-COPD Gender-CHF Race- COPD Race-CHF

28

suggesting prioritization of improved access to quality care among minorities with critical health

issues” (Cook & Manning, 2009, p. 1609). Helping patients to bridge this gap is instrumental to

reducing readmissions.

Figure 2: Intervention by Diagnosis

The second objective was to determine the follow up needs of patients diagnosed with

CHF or COPD post discharge. For the COPD diagnosis, 42.9% (N=3) received patient

education on signs and symptoms. Coordination of durable medical equipment (oxygen) and a

follow up appointment were each coordinated for 14.3% (N=1) respectively (Figure 2). The RN

addressed medication questions for 28.6% (N=2) the participants. Follow up services correlated

to readmissions in the first 30days with a significance of (0.194, p >.05); however this may be

attributed to the small sample size and .180 for readmission between 31-60 days. For the CHF

group, 85.7% (N=6) received patient education on signs and symptoms. The RN addressed

0

1

2

3

4

5

6

Patient Education DME

Scheduled ApptMedication Questions

CHF COPD

29

medication questions for 14.3% (N=1) of the participants. There was no documentation to

support coordination of durable medical equipment (oxygen) or follow up appointment by the

RN.

This objective aided in identifying the missing links that may have contributed to

readmission. The findings supported the need for continued support post discharge. On return

home, patients had medication questions and required reinforcement of education that was

provided in the hospital. Patients in the COPD group required additional support with

coordination of the home oxygen and a follow up appointments.

The third objective was to assess congruence between expected readmission and observed

readmission based on the LACE tool for patients diagnosed with COPD or CHF zero to 30 days

and 31to 60 days respectively. SPSS Cross tabulation, Symmetric Measures (including Phi,

Cramer’s V, and Contingency Coefficient) and Pearson Chi Squared tests were used for this

function. On admission, the COPD group reflected that 14.3 % had a LACE score greater than or

equal to 11 which correlated with increased likelihood of readmission. In the first 30 days,

28.6% of the patients were readmitted. As of day 31, patients were reassessed via the LACE

tool. On the second assessment, 57.1% had a LACE score greater than or equal to 11.

Subsequent review of readmissions for the time frame between 31 and 60 days reflected that

14.3% had a readmission during this time period. Based on intervention participants, there was

insufficient data to support congruence between admission LACE score and readmission for the

COPD using symmetric measures for the index admission (p = 0.088) or at 31 days (p = .350).

Overall, COPD patients had a higher than anticipated readmission rate based on use of the LACE

tool evaluation for the first 30 days and lower than expected for the period representing 31 to 60

days (Figure 3).

30

Figure 3: Expected Versus Observed Readmission (By Diagnosis)

For the primary diagnosis of CHF, the study group reflected that 57.1 % (N=4) had LACE

scores greater than or equal to11 on the index admission. During the first 30 days, no patients

were readmitted. On day 31, the same 57.1% had a LACE scores greater than or equal to 11. No

patients were readmitted between 31and 60 days. No statistics were yielded from cross

tabulation as all readmission measures were zero and constant. There was no significant change

from the index admission admit LACE score compared to the 31 day LACE assessment for CHF

patients.

The LACE tool identified one patient who was at high risk for readmission within the first

30 days for the COPD group. However, two patients (28.6%) were readmitted in the first 30

days. As an important consideration, one of the patients who received education on signs and

symptoms was instructed to report to the ED if symptoms persisted as noted on the phone call.

The patient returned to the ED and was subsequently admitted for symptom exacerbation. The

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0-30 COPD 31-60 COPD

0-60 CHF 31-60 CHF

Expected ReadmissionObserved Readmission

31

patient met medical necessity for the admission. Reassessment had emerged as an important

component for care transitions. As of day 31 post discharge, there was an increase in the

number of patients identified for readmission by the LACE index to 42.9 % or three patients. Of

this group, only 28.6 readmitted between 31and 60 days. When compared to the current

readmission rate for the hospital, the COPD group in this study had an incidence that was 3.2 %

higher. Conversely, for the CHF group, four patients were noted at risk for readmission on the

index LACE admission. The scores were the same for the index and 31 day reassessment. Of

this patient group, no patients were readmitted within 30 or 60 days respectively.

While the sample was small, the patient with CHF experienced zero readmissions in contrast

to the four which were predicted by the LACE tool. The prevention in readmission for CHF

patients is consistent with findings of Harrison (2011) and Ahmed & Rak (2010) whereas COPD

findings did not experience the same positive outcomes. The results indicated that the

introduction of the post discharge phone call did not reduce the number of readmissions for

patients with COPD. This group experienced a readmission rate of 28.6% compared to baseline

value of 25.0%. Patients with CHF had zero readmissions compared to a baseline value of 28.

Using the LACE tool as an indicator of readmission, four CHF readmissions were potentially

prevented by this intervention. Descriptive characteristics reflected key differences in the two

diagnosis groups. Causal effect could not be attributed to the post discharge phone call as a

result of these and other differences. Given the LACE model’s previous predictive accuracy,

there was potential that this group had over a 50% likelihood of readmission which was

mitigated down to 28.6%. However, there was insufficient data to support this assertion.

32

Limitations, Recommendations, Implications for Change

A noted limitation for this study was that the site was an urban, academic, safety net

hospital with a very limited study population. The PI had access to readmission records based on

return to the same hospital or other community facility within the same hospital system. The

patients may have been readmitted to an outside facility which would not have been reflected in

the chart review, thus impacting readmission data. The relatively small sample size and

convenience sample further limited generalizability or internal reliability. The LACE index has

only been validated to assess risk for readmission in 30 days and non disease specific basis.

Lack of validation of the RN Call Back Interview for the purpose of reducing readmission may

impact its use for such purposes. The difference in readmission rates and shift in LACE scores

suggested the need to evaluate follow up services on a disease specific basis and multiple

timeframes of assessment to capture changes in health status. Again, the small sample size made

it difficult to draw conclusions for the disparity that existed and what accounts for the success in

one diagnosis as opposed other. Further research and evaluation is recommended to explore

these facets. Repeat evaluation with a larger sample size was warranted to attain statistical

significance. Conducting this study in a prospective format would allow for greater controls in

terms of the tools and allow for use of a validated phone call at multiple increments in addition to

the LACE score evaluation. Future studies also warrant impacts of covariates such as home

health services, patient support system, and adherence with regimen for 60 days post discharge to

evaluate a causal relationship.

33

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http://hospitalcompare.hhs.gov/hospital-compare.aspx?hid=260032&lat=38.6212468

&lng=-90.2526163&stype=GENERAL&&stateSearched=MO

University of Missouri. (2010) Missouri senior profile. Retrieved from

http://mcdc2.missouri.edu/webrepts/mosenior/profile_reports09/29510.html

Van Walraven, C., Dhalla, I. A., Bell, C., Etchells, E., Stiell, I. G., Zarnke, K., & ...

Forster, A. J. (2010). Derivation and validation of an index to predict early death or

unplanned readmission after discharge from hospital to the community. CMAJ: Canadian

Medical Association Journal, 182(6), 551-557.

38

A

ppendix A: System

atic Review

of the Literature

Systcmatir RClicw h 'ldcrK'c Table Forrnat ladapted 'lith IlCIlllissiOll fronr lh()npson. C (20t I) Sam pic evidence table format for a s)'st~ma tic review In J Houser & K S Oman (Eds), Evidcllce·based pracUce: All imp/emclI/alion guide for ilea/lilcare organi:alio/lS (p 155), Sudbury, ~ I A: Joncs and Ilnrtlettl

A quality improvenrart The Impact of TIre Irrflua rce 0 f Nt.ighborirood Sociodcmogrnpilic Variables Continuity of care arId iu lcrvention lo facilitate

Clln h(lnc visits help r;.-d uce Postd ischargc Telcphonic Eill'ironrnalt 011 l>rcdicting Poor I'ost- mOllitoring pain after the tmnsiti(ll of older

hospi tal readmissiOllS? Follow.Up Oil Hospi tal TrcaJtncnt Continuity arId Artlde Title Discharge discharge: patient adults ftUn three hospitals

Randomized controlled trial. Rcndrnissions RcixJspitalization in l:l!.rnUy ~nd Joul1ml Outcomcs for I-Iospitalizcd pcrsp.:!Ctive. back to !lIdr homes.

Joumai: JoumaI Of JounlRI: Population llcalth Diagnosed Pntic~r t s Discharg~d Elders 'lith Heart Failure JOllmal: Journa! of Jounml: JOllnlnl of'!lrc Joun18l: 11"100 Surg Nursing Advanced Nursing American (;criahic Advanced Nursing 1I1anagelllent From ACUh! Inpaticnt Cllre

Society JOlrma l: JOlrma! of Psychia try

I),:x\hia. 1' .. Kmvct. S .. Bulger, J. , Hinson, T ..

Stahler, G, J .. Mt.1mis. J.. Soler. R .. Juvin )'R Canal. Sridharnn. A.. KoIodnt!l".

Wong, F., Chow. S., Chung. I-!arrisar. P. L. I-Jara. P. A.

Collar. It. & Baron. I). A Roe·Prior. p, (2oon Il . Noguer. C .. I'och. C .. K .. & .. , 110\\\;: 11. E,

L, Chang. K.. Chal!. T. Pope. J, E .. YOtrng. M, C ..

(2009). lhe infl llC!rce of Sociooemogrnplric variables Bnrgada 1"Ilotgc. N .. & Gil. (2009). A (lun1ity & Ruin, E. Y. (2011). 'I1re predicting poor post-discharge M_ (2010). Continuity of 1!llprol"~menl !rlterl\:ntion

Lee. W .. & I..ee. R. (2008). impact of llOSldischargc

nd ghborhood envi ronment Oil

Clln horne visits help redll~e treatment continuity and Author/Vea l' OI.rtcomes lOr hospitalized car,,: and moniloring pain to facilitate the transition

hospi tal readmissions? Iclephorlic fOI!O\\'-llP on

rdlospila!ization in dually ciders \\ith heart Iili l rre allCfdischRfgC: patient of older ndlll1s li"orn thrc.:

Randomized controlled tri al hospital rendmi~siOlrs,

diagnosed patienls discharg..--d MEDSUI?GNtlr$ing. /6(5). pcrspccli\'c_ Jour/tal Of hospitals back to thdr JOlmla/ Of Advallced

Popu/mion Heallit Ii'om acute inpaticnt care.

317-321 . Ad"'Ulced Nursillg. 66(1). homes. Jouma/ Of The Nllrsillg. 62(5). 585·595.

Managemenl.14( 1).27. Anrc'fiC1ln JOtlma! of <10-48, Americall Geriatrics 32.

Society, 57(9).1540· Ps),chialr),,66, 11258- 11268

1546

lMabasc ~nd M~d!inc Acailimric Search Prclll it!l" Academic Search Premier CINAI-!L Academic Senreh Pf()micr CINAI-!L

Keywords 1"I !i:dicnre & Rcndmissiorr Discharge Planning Discharge Planning & Discharge Planning and Discharge Planning and Discharge Planning & readmission readmission readmission readmission

Hesl'a rrh sccorrdary analYlIis

longitudinal. prospectiv.: Qlla$i-c;.:p;.'TinH!llta! randorlli ~.cd controlled trial rdrospcclivc cohort siudy rdrospccli\'c analysis

DeSign and observRliorrnl design pr.:>-post study design

39

40

to ~ • 0 = .:::

• 0 ~ O

;; . ~~ ~~

41

.§ ~ '0 0 ·u

:. .= :c g ~ 0

~ g ~ u ~ ~ i • ~

""-;:: e " g -~ • M :o.!':;:; a

" .:1 g ~ M<

= -"::: '" .£ :'§ 8 ~ g,3 ~ ~ - 0",

.::: ~ 0 ~ 8.. ... x ~x

< . ~ ;;

~ >,. §] 0 .= ~

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i5; 8: ':;: 0 ~ .§ ,

.s '5 g 0

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0 .; !l :s ~ ~ ] 1l ~ '5

1 ~ jj -" as ~ Lo ," ":ti "g E ~ 0 j ~ " ~ ~ . '" • •

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.~ g:-g 8::' >- g ~ ~ • ;; ~ ~ " '5 -;; V) "ii. ~ _~ ~ "§. ~ t -§ ::: Q4) '" ", · ~"@ ~ s] ~ .. 2 :s ] s "

~

"8 - ~'Z= § j .l! -E " ~ 5 -~] .~ ~ = ~ M £ -~ .s , ~

, 2 = · ;;:; g~g 0 @ 3.. e v,8..-9.g12~ .l! .=

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7 8 9 10 II 12

l,.e\'cl or Ib Ib II. II, lb III

":,idcnce

The purpose of the research 'Ihis study was designed 10

This snLdy is an evalulltion To dctcnllinc the speci fic case study was 10 ident ify

lest care To determine \\hcther the To evaluate hearllailurc

ofCM impact 011 behavior lllan llg~lH..'ll1 tasks and how

Study factors thaI place palients

coordination eflecls in a Ct-.. IP (Case to..fanag.:,"Il1C1lI

inil iali,"c for polenl ial lo change, risk· factor

Ihese AhniPurposc

\\ith cancer al risk for population of chronically ill,

l'rogrnm)roouccs ED vi sits reduce readmission in CHF

monitoring, self-functions related to, or

unplanned oldcr-adnl t, Medicare fee-roc- and hospitalizations 8n1ll1g

palients discharged to SNF manag\l1l1cut skills, lind

enhanced. lateral trnnsilions in readmissial within seven

service beneficiaries frequellt users. guidel in~bascd

days of discharge. phnnnacothcrapy care.

78 patiCll tS WI.:rC selcctoo from those readmilled

65-year-old and older Heart to HC/lrt \\ithin Sl."'\'tl1 days of discharge. For

Medicare·enrolled, is a clinical trial evalunting

each readmission case. a community dwclling; C~ I Joc CoronBry heart

I'opulalion nCl~rclldm i l1ed Participants had at least <X1C 1l'"491\.'gistcro:llCr" Case discase (CHD) risk redllCtiOO of fh'c Chrolic health management sm'ices to in a mu1t iethnic,

patlcnt was randomly Studiedl conditions: 1500 CClltrol; reduce ED utiii7.ation ; CHF patients dishcargcd to low-income population: Patients of rural ootpatit.'Ot Sam~c Siltl selected and matched on 1500 treatment groop comparison 160 of SNF Patients al elevated cardiac medical clinic ~'ri ri I I' discharge date and atriallihrilla tioll. coogcstil'c uninsured palients without risk werc randomized to n ·1 tClIowcr fI . d . . reason oc pnor II I1I1SS1011 .

heart fllilurc, COfOlary artery Case Managemcl1t plus The age range was 22-87

disease, chronic obstructive primarycare(212 palioots) years, men and

pulmonary disease' aSlhmll, or to primllrycarc II10ne \\I:lInen \\\!re equally represented. and 88'l-0 I\\:re

or diabetes melli tus. (207).

Caucasian.

43

44

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45

13 14 15 16 17 II

Relalionship be\ \\'eC(l ERrly ~llpacl of case managemcn l C ,. . . , ase managomenllor pallen\S Case management by lIn.' . . physIcian follow-up and 30- Ri k' I' 30.1 by advanced rrachcc nurses . h h ' I· h . . 'ua1 IS lI11 portant!ll cancer , . S· Ifict(]"S (]" -uay .. \\1\ C rome systo Ie earl ntl f'lil.."S,l!1 pnlllnry care: care coordinatioo? A day~dlll!SSlO:1 ~m.ong hospital readmission in U1 pnmnry cnre ~1 failure in prima!)' care: 111t

Article Title analysIs of73 'success 1" '" medicare henehclRnes . ~5 f ullplalUloo hospital HIO ! und Journal stCfies' qua UnU\'c m\'cstl gal1C~1 hospitalized for heart failure pallCtllS - years ~ age admissioos: a control led I nn .

j I. j I' l'ri 1ouma!: European Joumal of j I j 1' 1 I· j I f b ln181. Da)1or UllIver5lly , . d exploralOl)' randoTIIl sed oumB, (lIma In mary C C ' (lIma : } II J . (lIma 0 I I ," I C .. ~~. intervention stu y 11 __ ' ' I

C ance!" are ! A ' ~ Icd '! II wlca el:ller IlOCi;\;u lllgs J 1 mlc H !! contro w Ina arc ! Ie l~l~lcall l Ica (lIma: I ca t I Jounml: Trials

i\SSOClatiOlI &:n'lces Research

Hernandez, A, Greiner, ~ I.,

EI . G " f ll · 'I F~wow, G" Hammill, Il, S· I '~I " 1.1 Hu\\"s, D, \V" CashlllCfc, D., ' 11)11, " 1"11 IBmS, II., II / I"' j \' j 1.1 'd ' h P \' C I verslCIIl , I "\,!,I1, ,, N ' "R G R"'~ I' Kl· F C h'll S R~ ' C N b 1"1 8:)11", ollng. ., etel:lrClc , " aney, " ~ I S " j & e"e(lI1~, .. , I.NI,;I LS, eters· 1111111 , amp ~ ,

wOrts, ", ~'COOI c, 1,1· j " , P & ~ , L (2010) , = , " , Olg, " C If , J & EI G 1,1 v ", ' CU 'I II R & V' J (2008) aIT! SOI~" ulll01\, " , .. I..Llrtl $" , II 'lI Z (2008) R' k " mCCll~" 11)11" COnalll1 ..., NII1Z ,I\' II er-

C·' lIIecnl, . b . SOLmION, ~ I. , MASYJ\ L., Relalionship bChl\::1l1 car!y ~ 8) a\ '30" 'I IS I (2008), Impael of case Tasch T, Szccsenyi, J. (2010) ase mana gel:nenl y , . , , , laclors Lor -uay IOSpltft ,

. . & While, K(20! I), \\1mlls physIcian follow-up and 30- d "" managemenl by ndvanced Case manag. ellllll! fI.Of pallents nli TSes Ulpnll1arycnre: . , . rea IIlI SSIOIIIII pahenls . , . .

Authorl Year I ' f 73 ' IIlllXlrtant III cancer cafe dayreadnllsslon among G'I> 65 f practice IIUrses III pmnary \11th chromc. syslohc heart anaySlSO . succcss d"? I" ' I~'" I" . < 01' '' ycnrso age. I __ 'I . I "I ' I , 'Q " 1 coor lIlal1(lI,A quallallvc l\' wlcarCuo.;;l1e lcmfl CS D. , U · . 'Id' , care on unp 1U1I1w losplla LalllTcmpnmary care: l1e SI01'lCS. lIa ll), 11 .,' L' h ' 1" '1' I 1'· 1 I)d)' or mverSIIYIL'e Ica d · ' - 'Id IIIC' I I P , ,. 16(2) 75 IIlvcstlgallOll, 1~ lIropeall OSp11l1 17,w or leart 81Urc. C P di' 21( ') n IllISSH)IS: a Con LL VL W . II all eXlJ oratory

nmary ..... are , , - J 10"C C j'llA J IOf'1 emer rocee ngs, " , . , d 8',·" d '", 1101 ' I 82 Q!IfIW ~ allcer are , 111 ' .' Ollma I ,Ie 363-372 IIItervenllOll slu y. w..... ran onll.')Wcon1ro tna 20(2), 220-227. AmericallMedical Health Sen'ices Research, Trials. 11:56

All"'iation, 303(1 7), I 716, I 1,7 1m

Ualabasc and , Med!ine Medline Coogle Scholar Googlc Scholar K d ~!cdll1lcCasc Mnllagancnl CINA I-i L Case ~! all agclll cnl C ~ I C ~ ! Casc Mnnngcl11C111& Casc Mnnngcmcnt&

cywor s asc, anagclI1cnt asc L· nnagcll1cnl Readmissioo RClldmission

Qualitalivc study , . , " . , , Research hedded " d explorative descnptll'e Ob' 1 l ' . . h d prospccllve IIltem:lltlQI exp!oralory pahenl·rnndonnsed DeSign elll

l, III a II' cr qualitativc ~'f\'atlOn a ana ~'Sl S retrospective co or! stu y study controlled tria!

eva uahOll,

46

IJ I' 15 16 17 18

Lenl of 11\ 11\ 11\ I. 11\ Ih

E\'idence

10 study the e!lb<:! of 10 develop and vahdate advanced practice IIUrse

explore Ihe To cxami llc associations predictors of30- case

determine \\11t.1hcr case explore Ihe ,"jews bt,1\\\.:Cf1 ootptlli~nt follow-up day hospital readmission man8g(,.~n (;111 011 unplanned

cllOOlivcllcss ora new model oj'

Slud), Aim' managcmclIl r.xlu~'S and c:.:perialces of key

\\ilhil1 7 days aller using readily avai lahle medical and geriatric CHF case management

Purpose unplanned patient SlakdlOldas 10 idal1ify Ihe key

discharge flUn a heart failu re ndministrahvc daln and to hospital admission rntes in conducted by doctors' assistants

adillissia l WlllpollCllIS of cancer care hospila lii'~1ti on and compare prediction models patients 50 years and

(DAs. (Xjuivak.1l110 n nursing lohospilaL coordinsli()l

readmission within 30 days thai use a lt.:nlat~ O\'er, and CXl admission risk role) and supported by genera!

ccxnorbidily classifications in a 'higher ri sk' sub-group pract itioners (GPs).

of patients in the UK.

·1l1e lotalnumber of Eligible patient'i I\\:fe adults

patients consentoo and the models were dcvdopOO I\; th ascertained lell ventricular

placed in a t\\t)-thirds random systolic dysfun ction (len

011 casc-manag(:lllcnt sample and validated in the vcntricular ejection traction 01"

cascloads Il'as 12 1. This rtmaining one-third 45% or Icss);expcctoo a tolal of

number semi-slmclured individual and SIIm ple. nl~ study cohort Five practices accepted the 140 patients. Given this sample J'opuilition

represents the overa ll lbeus grQI11)S intm'iell"S Ilith 30. 136 pts trom 225 consisted 01" 29.292 adults invitRtion to take part in the Si7.c. an clfect of about 0.45

Studiedl easel08.d taken (XI by the patients (n .. 20) \\"ho have hospitals. nil-' : age 65+ aged 65 or older

intervention anll . l1le ootlld be detected using a CXle-Sa mple Sizel

live oo::n tr.::a ted lor any \Iithill 30 days: participants \Iho were admilloo Irom remaining 30 practices in sidoo t-tcst with

Cri lerial nu I"SCS over the 12-month Cllnccr and cartl"s (n .. 4) as in Get With the Guidelines- July 2002 to June 2004 to

Swansea a signiiicnncc 1(..'Vel of 5% and a I'ow(' r

study. ·Ille mean age ol"lhc 1\1:1l as clinicians (n • 29) Heart Failurequahty anyof scvcn acutc foollOO thc nOll-intervent ion poI\l:r of 80%: ·!lIC 31

selected patients for ease involvoo in cancer care. using unprol"emcll t program care hospitals in the practices. participating physicians

managcment was 79 years open-(mdoo qucslions Dal!as- Fon Worth rccruited 19gehgib!e

(range 59-% years). mctropolitan arel! afliliatOO patit:nts: 99 patients were

Forty-t\\\.lofthe 73 \\ilh randomi!red to cssc

patia lls (58%) were fana!c the Baylor Health Care managallCllt and 100 to usual

and 46 01"73 (63%) lived System Rloue

care

47

13 14 15 16 17 IS !

A phenomenological approoch ~dodcl s including all orthe

one-sided I-Icst, descrip tive I \\,~ used 10 explore pis c;..:pcrit,'IIccs

t:va luation of 1 ... ledicarc CQvarialcs were analyzed sided p-values, and ANOVA '

Methods! and \'!cws:tdcphollc and face-inpatit,'nt claims linked with using bBCb\llfd eliminat ion

used: Patients cvaluated using: Study

I\nalysis of case manager to-face or foclls group

da ta Gel Ilith the Guidelincs 10 idcnhfy cova ri al~s comparing inh::rvcntiOIl \Iilh SF·36 questionnaire consists of !

APPnlisll1J casc rcporls in n scm cc

illl ~'fVicll's to collC(:\ Ihe slIIdy Program and f<.llistrics; significant at the P < 0.05 non-intCJ'vcntion practices

eight dimensioos;Europcall Synthesis

i ~novalioll evaluation data. Trallscri!}cd dala for

~ I cdi cnre I}Wr files used 10 k.-vel. Separate analyses from prc-i llt~r\'enti ClI 10 Hearl Failul"C Sc! f..(:aI"C

Methods study,

them~ via QSR NV"·o 7 examine readmission fRtes II\;I"C conducted for the inli,:rvention year,

Behaviour Scale: Patient and Ihe denauinalor fil es to Elixllallser and HRDES

(QSR IntCf11Rliona! Ply Ltd examine morta li ty rates eccnorbidi ty covariatcs.

Assessment of Chronic U!ncss 2007) Care

From this o\'era!l casc!ood primary outcome of interust

of 12 I patients, 73 'success was readmission to any of

unplanned medical and pre.ooservatioo lWadmissials

st()"ics' II'>!re collected Q..lahtative analysis idalh~ed Key measure: All "(:llusc the seven BHCS hospitals

geriatric ndmissial ra te 111IS higher than during f01l01\11P

Prima ry the fol lowing s;.:ven major readmission wi thin 30 days I\; thin 30 days of d i scha rg~ (36 vs. 35 cases): 18 ht:art Outromt

<!uring the year, indicating compona lts considCfcd by after dischllTge and analysis of the

signifi cantly Iowa' ill the failure admissions II'>!fC

Measures and tha t

part icipants to be essential al follow up pa tterns ~ paticnf s fi rst ndm issionto a interven tion group~ used

observed in I I patients in the Results

tile nurses felt they had f()" clTccti ve cancer care 21.3% of patients II'>!re BHCS acute care hos pi tal

Dayesinn intcrventia l group I\hi te 9 wa'.:1

made a significant JXlsitil'e rcgrcssial models using di ficrencc for over hal f the

coordinaticci readmittoo. inpatient WinBugs soft ware

r<.'C()"d ~d by 7 pati"1lts in the

patients on their casdoods. medical or surgical Sil'Vicc control group during the study 11'-";00

TIle intervcntion tailed to Among patients Ilho are

Rcsulls showed Although thiss!udYTCI)()"IS improve the ol'eraU gen,,'fic and

hospi tali 7.cd lOr henrt tililure, disease s11'-"'Cili. ~L: improved substant ial I'ariation exists in

that age 75 or okla , male a reduction in unplanned self care; decr~ascd

S(,'X. African AmericlUl race. admiss iccl ra t ~s in the Author

Estab lishing C~I at variOtls Case Ma!lRgcment hospital-level ra tcs of early medical vs surgicnl inl c:('vcntion practices, this

hOSI)itili t.ll tiollS, Lowmortality I~\'e l s of care (PCP- illiprovi.~m:nt efforts are outpatialt follow-up aller rate (- 5% in boUl groups) and

Conclusions! Ol'/Acllte) is important to hnm[X!l"cd by tbe laci; of discharge,

sa'l' ice, Medicare lI; th no appears to be only in part decreasing hem-t Iililu re hospitali

Irnpli ra!1ons or 1:loving patient alalS are oonsensus abOtlt the defin ition Plltients I\ho nrc discharged

other insurance, discharge to di re<:lIy due to nurse case admissions, there 111IS a

Key Findings continuum and scope of care coordinalitJl lrClll hospi tals that ha\·e

a ski lled nursing management: 1ll 0~t signi ficant increase in overaU

higher early fol!ol\~UP rat\!!; filci lity, and sp;!cific oft!w rcduclial did not

practice aU"::ldtinces in the havc a lower risk of 30-day

comorbiditics prcd:cted 30- occur in llIulti p;! admittcrs in tervention group but no

readmission dayreadmissia l ' Ihom were case managed

changc in cardiologist attendance,

48

13 14 15 16 17 IS :

Weakness: observational Siudy and patients were not S trc!1gth ~ of the study nrc that

Weakness: fnmil yphysicinns randomly assigned Weakness: included medical mnny aspects of the tria! \\\:ri; IUldt.'J'-representoo; based to carly follow.up~ cannot and surgical piS; [he promOloo high inlcmal validity. I (Xl patients' retrospective recal! ruleoullhe possibility of priXIicticxl mle is Randcxnizatioll waS of unmeasured l1<Xlllropriclnry, used did not match oc adjust for oonccalcd and conducted by a

Strc~rthsJ Weakness: No Q.lnn ti fying their C\:pcricnCl..'S that can lcad ccxlfounding. '!lIe analysis c;o(isting hospital resources diffcrcllC\:s between third part)~ there m::rc analysis; subjective; to fetal! blBS; The seven \\llS (strength and limitat ion); intervention reasalably equivalent groups of'

Limitations rCporling hias; not randO'll th('~ll(,'S and Ilm,'C CCfC elcments restrictal to fec-/oc·scrvice possihle ovcMtimati(l] r/t and n0l1·inl~n\,'l1ti()1 pati~~l t s at baseline; \Vcakn ~'Ss: i

identifial McdiCllfc planned readmissions, practices it was impossible to blind in thi ~ study mJuifc further bellcficiarie:<; enrolled in greatcr than 50 miles- providas 10 treatment gmlp, va lidation and a'luanlila live heart failure possib;e readmit outside of \Iilich may have biased Iheir evalua tion climeal fegi stries, and S)'Slem activity as III';:!! as palietll

hospitals that participated respalses to questionnaires in the registry differed from Iloopartieipating hospitals

Gel Wi th Ihe Guidelines-Heart Failure is a program of '!lIC study was supported by the i

TIlls study was funded Ihroogh the American Heart CO'llpctcncc Nchlm Henrt

The authors repm no Association 111e study and evalUftti(ll Failure, limded FUIHIing

external hlllding foc this a Health Services

and is supported in part by Da)1or \\3S fundal by the S\IRnsea by the Gernlan Ministry of SouI're Research Grant from the

study. CanOO" ~lslitute NSW.

an unrestricted Local IknUh Board. Education and Research ooucatiOllal grant from (B~1B 11, grant no GlaxoSmith Klinc IUld 0lGl0205 ~ Ied l rollic,

Paticnt/Musltdisciplinary Analysisofhigh risk

perception ofCM role is Capstc.1c to inclildc chart readmission groups calls 'Ibis Shldy poses thc 111lS study lOCus on CHF

Plnn to inoorpcrate important to cfioclivc delivery

review of Mooicare nl!CIltiolls to subscts \\hich (!ucstioll of c\1cma! patient \Ihich Ilil! he targeted O ml11(' Il IS qualitative and quan!i1Jltivc popuRlion· trcnd dala lor this may WRrTant additi()lal variables thaI may impact for inl~m!llli()l· additi(llal

elemcnts into the analysis of cnpslooe intc!'Ycnric.l;

population is an impmant focus during intavel11ion; Capstone- yet another disease speci fic insight is IncCflxotc militidisciplinary

cc.lsidcmlion lI~in g a prroichvc tool for imporlant considcration important clemcllts into capslOIlc,

cvalu8tioo

49

19 20 21 22 23 24

Reduccd emergency readmissions and improved quality of lile for otdt:r adutls al Cost-effectiveness of a nurse- Posldischarge Environmental risk ofhospilal readmission: A 1o.Icdicalion randomise<! controlled 'rial to

loci case managcrncnl and Socioeconomic Factors Redclining Readmission Recurrent Readm issions in Reconciliation al

A11it'lc Title and dclcnnine the effectiveness of a inlcn'cnlioll in general and the Ukclihood of Early Risk Factors for General Medical Palients: a

I [ospi tal Discharge: medical ()Ulpatialls Hospital Rcadmissioo Among }.·Icdicinc Patients Journal : Prospective Study Journal:

Journal 24 compared \\i lh usual care. COlll lllunity·Dwelling Joumat of Hospital Society of II os pita I EvalUllling Discrepancies \\\XI.: exercise and telephone Journal : Joumal of }' Iedicarc Benefi ciaries Medicine Medicine

10u01al: Thc Annals of follo\N lp progralll. Psychosomatic Research 10umal: The a....,.onlo1ogist

Phannacomcrapy Journal: Joumal oClllc Am{.:rican Gcrialric Society

I..atour. C. II. ~-I., IJosmans, Courtney, ~1.. Edwards. 1-1 .• J. K. Van Tuldcr, ~1. w .. Dc Chang. A., Parker, A .. Vos. It. Huy~ F. 1.. ]);: Arbaje. A. I., Wolff, 1. I~, Yu. Mudge. A. ~1.. Kasper, K., Woog, J. D., Bajcar, 1. Finlay-SOIL K .. & Hami lton. K. Jmgc. P., Van G<:int.'I1. L. A Q .. l\Jwe. N. R., Anderson, G.

AllaudC<."'I1, N .. Vidyarthi. Clair. A., Rcdr~nl, 1-1., Bell. !-.L Wong, G. G.,

(2009). Fe\\cr I!mergcncy M .. ct al. (2007). Cost- r .• & Boult, C. (2008). A .. Maselli. J. and

1. J.. Barras, I>.\. A., Dip. G., A1ihhni, S. M. 11, Huh. J. readmissions lind better qualit)' eflectivcrless of a nurse-led I'ostdischarge environmClltal

Auerbach, A (2011), ct a1. (201 1). ROCUTTcrll H .. Cesln. A , Poud, G.

of life for older adults at risk of case managemClll and socioeconomic factm Redclining readmissial

readmissials in medical R., ct al. (2008). Author! "tar hospi lal readmissia l: a inlerveI"llia l in geTll2"al and the likelihood of early palients: A prospective MlX1icalion roconeiliatioo

randomized controlled lriall0 medical outpatients hospital readmission among risk factors for g;.:ncral

study. JOllrnal: Journal of at hospi lal discharge: determine the elketi vcncss of a compared \\;Ih usual care: an comlllunity-<!\\d ling

medicine patients. hospilal medicine all evaluating discrepancies.

24-\\"~k cxercise and tclephone CCOIlonlic cvaluation }' Icdicare beneficiaries. The Journal of Hospital offiCial publiCatiOIi of/he TheAllllalsof

10110\\,-11]) program. JOllrnal oj alalgsidc a randomized Gcrollfologis/, 48(4). 495-Medicine, 6: 54--60.

Society 0/ Hospital pharmacotherapy, the Americall Geriatrics conlrollcd lrilli. Journal of 504. Medicine, 6(2), 61 -7. 42(10),1373-1379. Soc/e/),. 5'1 (3).395-402. Psychosomatic Research.

62(3),363-370.

IJatabJ:lsc and Googlc scholar Google scholar Google scholar Googlc scholar Googlc scholar WilcyOnlinc libmry

KC)''''ords Case }.Ianagcment & Case Managcrnenl & Case Manag..'t11ClII & Casc Managl.:mcnl and Case Management and Discharge & Mcdieatial ReadmissiOlI Readmission Discharge planning Discharge planning Discharge planning re.cOllcilia tion

Research llesign RandanilCd eOOlTOlIcd trial Randomized controlled trial pI"OSpoclh'c cohort study retrospeclive

Prospoctivc coha1 study Prospoctivc cohort study obscrvatiallIl study

50

19 20 21 22 13 2'

Ltwl ofE,"idcnrc Ih Ih II. II. II. II.

To dctoonine the impact of To evaluate lhe eflecliveness of po5t-discharge, nurse-led,

'Jlliss\udy To identify factors an exercise-based model of home-based case To identilY factors To identilY, chamclt-,;ze, hospital and ill-home management intervention on

was a cohort study using Ihe as~ial cd lIilh

associated \\ith an increased and assess the clinical

Study AIm' follow-up care for older people the number of emergency 2001 Medicare Curren! rca~missiOIl \\;Ihil\ 30

risk. of r~\llTc1l1 readmission impact ofuuintcnliollal l>U rpost

al risk of hospital readmission readmissiClIS. level of care Beneficiary Survey and

days for generalmooicine in medical patients Ilith 2 or

medicatioo discrepancies IIfcdicarc claims fIX the more hospitn1i7J1tions in the

(Xl emergenty health service uti lization, period from 2001 10 2002.

patients. paS! 6 Illoo!hs.

at hospital discharge uti!i7.a tion and quali ty of life qua!i lyoflife, and

psychological functi(lling.

On the oasis of data from a 150 patients were

pilot study and a litcrature 128 pari ClllS (64 illtcn'alli(ll. search, the ri sk of OOInmunity d \\\:!!ing

included inlhe stud)', genCl'al intooml medicine

64 ~oulrol) \Ii th an acute rcadmissioo \Iith in 6 111<lllh$ Medicare 142 inpatients aged 50 years patients admined fer al

medical admission, \1115 estimated bcnc~ ciaries (all ages) \1110 col1ort included 10,359 \I;th a prt.'Violl$ least 72

aged >65 yC/lrs and with at to be 50%. '!he hypothesis participated in C()I1scclltivc admissions hospila!iza li<l1 6 moulhs h().lrs . Patients

I'opulation lc:/1sl one risk fncler fer \1115 that if this pcm:ntagc the 2001 round of the II le13S, (6805 Jlllticnts) discharged preceding the index excluded if they WefC

Studied/ Sample readmission (Illulliple could be reduced to 25%, II were continuously Ihxn the gcneralmedicinc admission. Patients from discharged \\;th vcroa!

Sile/ coillorbictities, tollli of 130 paliClllS (65 enrol led in Medicare SI.'n'icC', administrative residential care, \I;th prcscri pli<lI S~ died durin~

Crite!ia/ Power impaired ti11letionality, aged per condition) 1I'0uid be th rotlghOlll the calendar year, database at 1111 urban 550-ta-mina! illness, or \I;th hospitalization; or

>75 years, recent multiple needed (a lpha: 0.05; power: wCI'e hospitalized during the bed !crtiary care academic serious cognitin: or language IrnnslCrred hun or to a

admissions, poor social 0.80). period from 200 110 medica! cell ler. difficulties WefC excluded. nursing home, another

support, E.'l:tra palien!s m!re sampled, 2002, and were discharged institution, or

history ofdcprcssioll). laking drop-olll alia home(N - l,35t). anocher unil IliUlin the

rnndomizatial same hospital.

inlo accounl

51

19 20 21 22 23 24

COlllllrdlcllsive nursing analysis per in lenliol1-lo- ;":a1io1l1l1 sample of "' lcdicarc Cohorl pIIti(!ll1S were Ixmographics.

aSS<.'SSlllcnl oombincd with treal principle. ElTctts on ~ncfi ciarics ( (IUafterly, in- discha rged from the l>.!cd icatioll exercise, heenc visi ls, and emergency readmissions person interviews on runge of general medicine service

hospita lizations. diagnosis. discrepancies ll'a"C

COIllC4"bidilics and nulrilional l\l ethodsl Study wlephone \\\,:1C (,:xpr,::si;Cd in rela tive socioocrlJographic and hcnilh Ol'e!" ft 2.yenr period;

slntns \\\!rc recorded in nssesscd and

Appl'lI i8all follow-up for 24 \\\:eks: risks (RRs) and their 95% 10pics). Claims linked IV/ clinica l. opttRlional. and hospi tal. PIS assessod \\i1hill characterized lOr Synthcsls Methods Evaluation yin SI'SS lIillg using oonfid ence intervals (Cis). survey da ta including sociodclllogrnphic factors !)()Icntia! clinical impact

Chi KJlp!an.~ ! cier analysis and nonelecti ve readmissions in WCfe cvalnated for 2 \\\!cl.:s of hospitRI

of the unin tcntional discha rge using multiple

.'i(llll\re. Mann-\Vhitn(.j' U and t logrank to establish the year follo\ling initial association \I;th validated qncslionnaircs

discrepancies . tests dilferences in groups admission readmission.

·IlIC intervention group Pa tients discharged home ·Ille 30-day readmission Unplanned readmission to f\X)uircd significantly less fron a hospi tal Of the 1,351 benefi ciaries. ratc was 17.0%; 49.7 the study hospital within 6

106 patients w/l or I elll(''fgency hOl.llital (N 147) \1\":fC randomly 202 (15.0%) e:":p.:!ri("lciXI an \I;thin !O days. In months. 55 parlicipants

potential discrepancy. 62 readmissi(lls assigned to usual care or early readmissi(ll. After multivariate analysis, (38.7%) had unplanned

I'll at least (lIe Rctual ( 2 ~(, of inl(:1·','<-'Iltion gronp. nurse-led casc management adjushll(!nt for dcmographics. factors associated \\;th hospital ad~l i ssion l\i thill 6

discrepancy at I'rimary Outcome 47% of control group. inlervention health. and fnn ctional status. readmission includlXl months. III multi variate

discharge; Most Measures alKI P=0·007): and emergencyGP [).Iring the 24 1\I.!cliS of the odds of earlyrcadmissi(ll black :ac;:. inpatient use of nnal)'1>is. chronic disease, C(lnlllon: presenpl!OIl Results visits (25% follow-up, no differCll,e were incfCllSi!d by living narcoll,s and dcpressive S)1nplOms and l"IXjuiring clari lication &

of inter:enti~l group, 67%of bctl\1!CIl the tl\1) groups was alone. having nnmet corticosteroids. and thc undcrI\\:igh t 1I\.'fe predi'lors omission ofrnooications; control group, 1)<0·001). '111e found functional need, lacking scll: dIsease states of cancCl". ofreadrnislion afk'f 31 I'll potential 10 cansc intcrvcnli(ll grolll) also tOr readmissi(ll, care management skill s, and renal fa~lurc. congestive adjusting b age, length of patient di sc(lnlbrt and/CW"

reported utiliza tion, ()uality of li fe. or having limited edncat i~l heart faIlure. and IWlghl slay and functional status clin ical detcriora ti (ll . . .

These

Early introduction of n tailored Endings suggcsllhat PDE and

Readmission of genera! SES factors are associated

exercise program and Jong tcnn Cascrnanagcment \1;lh early readmission. mcd i c in ~ pati(.~\ls \lithin In this higll-risk palialt ~ ! cdication discrepanci e<; tekphonc 10110\\,-\11/ may shO'.Ild slart inlhe hospilal.

Considering these 30 days IS C0I1Hll(l1 and I·! I · occur C(llHllonly 011

roouce elllerg~ncy health so that the caSi!lllanager . grotll), mu 1Ip e c ll"OlltC .

lindings mfty enhance the assocIated 1I1th s(.'Vernl d"t" d hospital service utilizat~on and improve can formulatc a care plan

COIl I lOllS are COlllm(ll an . Author

targeling of pre-discha rgc ~osll ~ . . predict increased risk of discharge. Understanding Conduslonsl qunlity of !ifcof and discuss th is \I; th

and pastdischarge Identifiable chnlcal and d · · I' I . I the type and frequency of I lI1pll e~ tlons or older adults at risk of hospital the pfirnary-care ICII1li

. rea 1llISS100. osl- losplta . interventions 10 avert C.1r!y nOllchmcal factors . . I!d discrepanCIes

.. . . mtcrventloos s 10'.! .. Key Flndlngs rClldmissi(ll. l..ooking al lx!forehand. Ilith nlt<:lltiOll to readllli ssi~l . !~enhhcatlon ofthes;: .nsk cOllsider targeting nutrihOlla! can empower clmlcians

ntUllbcr offeacmissions. the thc Such intervent ions may

factors can alloll' prol'ldas d ood .! . 10 belter understand \llIYS intcr:a lti(ll group hod 21 transition from hospital to

. . an 111 51atus mtllS include homc Iwnlth to target mter:·entl(llS to nlation to

readmissi(llS compared to h(lllC. sen·ices, patient acti l'ati~l.

reduce potentIAlly pop prevent them. 49 ill Ihe control group

and C(lll ilrehensil'c discharge avoidable readmissions.

planning.

52

19 20 21 22 2l "

Weakness: 1l1ero were larger Strength: patients were numbtTS of interven!i!)l group assessed prospectively, participants \\ho withdrew Weakness: unable to linal recol1ci liatiill frun tbe study 'Rpture admits to outside coding IIllS completed (6.3%) when compar.::d to Ihe

Weakness: bl inding of the hospitals. inclusive of rc1rospccti vcly \\;thin II

Stl'Ctll,,1hsl ronlrol group (0%), Just over n

palienls Strength: national survey-increased patia ll Icyel few

qUllrl(:f (28%) of the dala, hch::rogcncol.ls U.S weakness: slllall sample size days of discharge, Limitations

intervtl1!ion group were not \lllS 1101 JlOSsiblc. Partinlly Rcprci\i:Iltativc

inpatient medicine variabilityamC41g compliant \\;th the exercise

based 0 11 sclfrcpm population \Iithotl! assessors; only actual

program. ,\hich may hal'C IimitatiC41 hy age Cf payer unint(:lltional dilul~d the sialus discrepancies \\'CI"C impact of Ihe inlcn·cn tion on nssessed for clinical outcomes impact

·Ille Dulch Hcnllh Insurance Council supporl~d this

TIlis study was limdcd by an siudy \\;111 II rcscarch grant

TIlc authors rcporlno 11lc authors rcport no (00251 ;"Prc\'cnlion orRc- University Heal th

Funding SoUiTC Auslralian Research Coullci l Admissions

CIIIS ex!1l11al funding f(X this exterllal funding h this Nel\\orl:

Discovery I~CCI Grant hy 1I·leans oj" Regi(Xlal Care

Sllldy study

Coordination") to Dr. 1'. de J(xlge.

Undt.:rslanding risk lilet(Xs This stndy highlights the

lOr readmission is ·nlis study !hills tho need lOr stmclured

Attrition is important f(X the 111c national rcsllils lor important lOr Capstone as emphasis from mcdicati(X1 rcconcilia ti(X1

inIL'l"Vellti (Xl; cx(''T"Cisc may be a Capstone as R llU rse led 1I1CBS serves 8S lin indicator it rdat~ 10 fCfining nonmodiliablc disease Rnd to prevent dischnrge

Commenls barri er. not anticipated 10 inteIVcntioo: Wi n inclnde

ofpaticnl needs lOr discharge- proct:ss and addressing demographic predictors discrepancics-incorporate into intervenli (XI cvaluation ofemcrgcncy

can be llsed in faci litRt ing risk facl(Xs: Capstolle 10 to c(XIsidcrnlion OfCoo1l1l01l, intervcntioll addrcsses based on find ings: r~1dmissic.l ViR LACE tool cnpst(Xlc to pfCvent readmit ine(Xl)()flltc mcasuranen! nondiscase 3p.x:ific factors; need for assessing Retrospective to amid Rttrition.

of needs identified post \\;11 int(.'gra!C age peramctCf undcrslanding of

discharge (50 years of age) medication ~,."t; .,.t,"c" "

53

25 26 27 28 29 30

II lediClllioll detai ls Rela tionship l3e\wcen l ... !edicalioll di screpancies at

documentoo 00 hospitnl Palient Salis!act ion Wi th

Costs of Heart Hospital Readmission Schooulcd and Unscheduled

discharge fron nn internal dischnrg.:: cross-sectional

inpatient Care and Hospital Failure-Related Am()lg Participants in n

I-Iospita! RClldmissions Amoog AI1irle Title and medicine service J().lnlal: obSC/'\'ational study of factors

Readmission Within 30 !-!ospila!izati<llS in Palients Transitional Case

Patients With Diabetes Joumal

European loumal Oflnl c:rnal associated \\i1h mcdicati<ll

Days Journal: Aged 181064 Years II lanagemcnt Program

1ournal: American Journal Of non-TCCOIlciliation Journal: American Jooma! Journal: American Journal

Medicine Journa l: Briti sh 10urnal Of American Joumal Of

Of Managed Care Of Managed Care Managed Care

Clinical Phannacology Managed Care

Grimes T, 1) lggan C. (J Boulding, W., Glickman. S.

Brien P, et al. Medication Wang, G., Zhang, Z., Alnlled, 0 ., & Rak, D. Hcrrcro-HClTero. 1., & Garcia detai ls documented c.l

W .. Manary. M P. Ayala. c., WaU, H" & (2010). Hospi tal

Kim. H .. Ross. J.. Me!klls. G,

Apllricio, J. (20I!) hospi tal discharge: cross· Schulman, K. A, & Staclin,

Fang, 1. (20 10). Costsof Readmission Amc.lg Zhao, Z .. & Bcxx:har, K.

"!edication discrepancies at sectional obSCn"BtiOllnl study R, (201 1), Relationship

l-leart Failure·· Related Participants in a (2010). S~hedilled lind

Authorl "ear discharge Ii"o:u an inMnai of factCl"s associated lI'ith Betm:en Patient Satisfaclicxl j'!ospitalizftlicxls in Patients Transitional Case Unschedulal 1'lospiTal

medicine service:. Enropcan medication non· With Inpatient Care and

Aged 181064 Years, ManagclIlt.1l1 Program. Readmissions Among Palients

Joumal Uj"lmemal reconcilia tion. Ori ti sll JOllmal Hospital Readmissial

America" Jc)ljmal Uj" America" JOllmal Uj" With Dia\x:tes. America"

Medicine. 22 (1 ). 43-48 Of Clinical Phannaoology Within 30 Days. American

ManagcdCare.16 (1 0). Managed C(lre, 16(10). Jou mal OfMa/wgedCare,

Jonmal OfMwlagedCare, 16(10), 760.767. [serial onlinel. March

17(1), 41-48 769·776 778·783

2011 ;7 1(3)"49-457.

IJ:ltubase and Wiley Online ]jbmry Wiley Online Library

PubMcd PubMed PubMcd PubMed KCY"'ol'ds

Discharge "!o:lication Discharge Medication discharge planning discharge plnnning discharge planning discharge plnnning

retc.lciliatic.l fe<:oncilia tloll

Rcscar~h l)esign descriph\'~, f(.1rospcclive. cross-sectional, observat ional

observational analysis observational analysis Retrospccti \'c cdlOrl study. Population.based data sci

study survey study.

54

II • ~ " = ~ -" ~ ::l ,B

j t

:g " ~ ~ '"

.~

55

25 26 27 28 29 30

survey using consecutive 1'I luliivariable logistic Dala anslyi.oo using Using Ihe 2006 Califomin

r(''ViclI'ofhospila! discharge Stale rcpcrls; DiSl: rcpancies \I\:fi:

di scharges from selected regression analysis for ~ !ul'i varia'c regression 10 multi \'arinblc logistic !nl)'11icnIOatasct we

Method51' Study idallificd. catcgori;r,cd and services in two acute public relationship bct\\\:cn patient Rnalyze the association regression. RClIdmissia l

idt:lllified 124.%7 patients 50 Appt'llisa ll characterized through the

hospita ls ill satisfaction rcporls lI'ith the OCIII'iX:!1 pa titmt predictors includod TC1\! years or older \,ilh diabetes

Synthesis analysis or lhe infoon81ion Irdnnd J .. ledication hospitnl slay, staff, characteristics and oolh ('11gagClllt111, length of sIn}' \\110 \\\:rc discharged

Methods (mcdica!ial lisls, labs. roconcilia!ion, potential fC4' discharge process. and 30- hospi tali7.a!ioo for the ini tial

from ncu!c care hospimls diagnosis, and clinical

hann and unplanned day readmission ra tes \Iilile costs and leng!h of slay hospitalil.a lioll, cos! of OC!Wilell April and S(.:pl(mlbcr cvolu !i~l)

fe-admi ssion III:re controll ing for clinical (LOS). inilial inpalienl slay, risk 2006 and cXJuninoo

il\vcsligaliXI. pcrfonllance. score. age. and scx. readmissions in the Readmission rates wefe

954 dischnrge reports In !Illmples ranging from lo\\\,"'!' for TC~ ! compared to nnnlYled- discf(.'Pllncies in TIlC ~imnryou tcol1lc I 798 ho~pit nl s for acute The cost \1 'R~nhighcr \lilt:11 control; 12.66%ofTC 1'I! About 26.3~~ rcadmincd 832 (87.2%) ofthclll mCllsure Ilns medication myocardial infarc!ioo to I-IF IIll S a !;C(;ondBry mlher grulP \I\.'I"C rcadmincd 10 the lI;thill the 3-monlhs; 87.2%

I'rintl!'):, Justified discrepmlcics 828 noorccoociliatioo: identified 2562 hospitals for thnn the primary diagnosis: hospital compared Ilith were unscheduled: 115 were

Outcome (86.8%): ur~u stified iu 50% of 1245 inpatieut plleUmali ll. higher hospital- hospi tnliUltioos J5.85%of those not potentially preventable

MCllsures Ilnd discrepancies episodes, level palient sa lisfaclion lI;th '-IF as R secondary par1ieip.1ting (P <.0001). In Sehtxluled readmissions were

~sult s in 52 (5.4%), Omission ora involving 16% of9569 scores lI\!re independently diagnosis resulted in S3944 the lirst 30 days, nOll less likely 10 occur among medication in 86.4% of mcdicntions:nle majori1}' had associated \Iith 100wr 30- higher cost ~ thanthosc participants in TC~! were patients 80 years or older, the cases, polentinl to result in moderate day readmission rates for lI;th I-IF u the primary almost <I limes more likely uninsured & unscheduled folloll'oo by incompl(..1e (63%) (Y severe (2%) hnnn acute myocardial infarction diagnosis (P <.0(1) 10 Ilavc a hospi tal initial admit. prescriplioo (9.6%). and Pneumonia readmission.

High",. ov(..'rall patient satisfachon The prcdict(Ys oJ'schcdulcd and s,1hs!ilction with

Ap~oprinte routill e~ to discharge plnnning nrc !nfonna ti ~l ~l Ihe costs of

and ensure an accurn te

associated HFrclRled !mplC1m:ntation of a unscheduled readmissions are

mcdicatioo history colleclial lI; th 101l';:r 30-day risk- hospitRIiZil lions can be

tcleph(llie TCM diff(;fC1J1. Transiti(ll and a TIle Endings inlooll strategies program 1I11S associa ted care 10 pr;",\·Cllt unscheduled

Author methodic~ ! e!aborRtioll of the 10 facihtali: medicalia l

standardized used as inputs in 1I;lh 100wf ra les of readmissions

Conclusions.! I11cdicati(l\ list at di .schnrge, recollcilia tion on

hospi tal readmission rn lcs cc(llomic evaluations such readmission \Iithin 30 days. in acutely ill patients with

Implications or IIhen pcrfooncd by Imincd discharge from acute ho~pim l

a1ler adjusting tOr as eost-c!lix:tivcllcss Timely engagement diabelcs may help

Key Findings intern ists, are care

clinical qURlity. lllis finding analyses and as reli:renccs in TO.I was associated lI;th reduce rates, improving cnre impOOalll for 811 adequate

suggests Ihal l)ft lia llcaltcred lOr policy makers in a 10wCf likel ihood of Ftrr1her studies

medication rcconci!ialial infonnation can have an making r~urec allocation

readmission. arc needed on potential impOOanl role decision ~

process in the evaluation and

disparities in scheduled

management of hospital readmissions,

performance

56

• j

57

Appendix B: Logic Model

Resources Program Outputs Outcomes Impact Aeti\'ities

Staff Nurses -Review -Patient -Increased -Short Term: Discharge orders knowledge of knowledge and - Patient sati sfaction on discharge with patient DC order and awareness of -Reduced Readmission at BJH -Address questions plan discharge regimen regarding - Post di scharge -Long Term discharge adherence to -Reduced Readmission at BJH

plan as inSl mcted -]mpro\'ed Nursin" Resource allocation RN Case -Collaboration re : -Patient -100 % -Sh0l1 Term: Managers planned Disclwge Feedback based COlilmunication with - Streamlined Patient throughout

-Post Di scharge on phone call , designated patient -Reduced Readmission at BJH phone caU - Follow through populations post -Address questions with OutlXltient discharge to -Long Term regarding provider post facilitate care -Sustainable Outpatient Management ror discharge discharge managenlent patients

-Reduced Readmi ssion at BJH Case Support for -working data for -Increased -Short Term: Managemcnt project/access to case analysis awareness of system - Slreamlined Patient throughout Lcadership data - Enlluation of issues and pat ient -Reduced Readmission at BJH

measures for needs regarding future patient discharge planning -Long Term care and -Medicare Compliance transition -Hospital Decompression mana"ement -Impro\'ed Resource Allocation

Pharmacy -Collaboration re: -Remodng -Increased ability to -Short Term: Medication Needs barriers to obtain medications, - Increased Patient Satisfaction -Address questions obtaining -Reduced wait time for medications regarding medications as -90% Medication -Reduced Ri sk for polypharm.1cy Medication needed cOlllpli:mce post -Reduced Readmission at BJH

discharge - RN education -Long Term as needed -Reduced Readmission at BJH

-lmpro\'ed Resource Allocation Community Collaboration re: -Pro\'ider follo\l' -90% follow up with -Short Term: Based Clinie/ Di scharge Follow up as ind icated pro\'ider post - Increased Patient Satisfaction Service pro\'ider up - Follow through Di scharge, -Increased Pro\'ider Satisfaction

with -Ilnpro\'ed OP -Increased compliance with Follow up Outpatient Management Appts pro\'ider post -Reduced Readmission at BJH discharge

-Long Term -Reduced Readmission at 8JH -ltnpro\'ed heaJthcare utilization patlerns

Hospital Provide DC orders -I nterdi sci prinm)' -t OO % - Increased Patient Satisfaction Provider to facilitate collaboration re' communication with -Increased Prodder Satisfaction

diseharge plan patient 's DC outpatient pro\'idcrs ~Increased compliance with Folio\\' up need and Case Appts -PrO\'ision of Managcmellt staff, -Reduced Readmission at 8JH C;,re ( physicians orders) -Long Term

-Reduced Readmission volume -COSI efficicnt 1X1Iient care

58

Appendix C: Conceptual Diagram

/

59

Appendix D: LACE Tool

Tab l. 1: LACE indtx fOf the qUMti/iC/ltion of ri~k of de"'h Or unp l&nntd rtlldm i"ion w~hin 30 d&y< &fttr di«h&r9<'

Anributt

Ltngth 0/ <lay, d ("L")

Acute (em"rgent) admi«ion ("A")

Comorb<dity (Ch.r lson ~om<>rbid ity indtx «ort1) ("C")

Vi,it; to tmt rgtncy dtp.rtmtnt dur ing prtyioLJ< 6 mo ("e")

Va lue

< ,

, , ~

7-13

' " ,. •

, , ,. •

, , ,.

Point>'

• , , • , , , •

, , , •

, , •

.,. r>otJ ...... t .... l.AC~ _. ;. "'"" ....... toy _"II thO PO:O;nt. Of thO

.,uib .... .... ' oppIy to ,hO poll .... . • _Chotl<on ,cmoo1Hdriy -. KO'. w.«ok .... 'od """II ' poin' to< ";'tor; ot """" .. lIiol int_ porip/>ofol _ u .. iii ..... , ...... ov.t(uor __ '" _ .. wWoout 'O<nPIi<or.iom; l po;n" to< "'''\JO'~'' "".n toihn . ,twonk ot..uu<,t.<o pu"""","1 d_. ",;td It."' _ '" """'"" ] point> to< _ti. 0, <""""'~ .. ....... _ .. ; • po:o;"" to. _ . ,. to """'. 1_ d ...... Of HJ\/ inf_ ond 6 point> tor ........... " """'" , .

60

Appendix E: Post Discharge Phone Call Template

RN Call Back (Interview)

Pa tient Name: _______ _ Age:---c ____ _ Roonl #.~~ ______ _ Date of Call : Admission D-aC-te-:.~~~~~ ___ _ Date of Discharge: _________ Discharged to: _______ _

I) Empathy & Concern MriMrs? Hello, Thi s is . You were di scharged from my unit on ___ _ I just wanted to call and see how you were doing today.

2) Clinical Outcomes/Discharge Mr/Mrs. . We want to make we do a clinical follow up to ensure your

best recovery. • Did you get all of your medications filled? • Did you ha ve your follow up appointment? • Are you ha ving any pain? How was your comfort level? • Do you understand your di scharge instructions? Any Questions? • Do you feel that you were given all the information that you need? • How was your di scharge process? • What can we do to improve the di scharge process?

Comments:

3) Service: • While you were in the hospital , did you have any particular problems with your

stay? Comments:

• Did they respect your privacy? • Did they round on you frequently? • Do you feel like your needs were met?

4) Process Improvement: • We ' re al ways looking for improvements. Do you have any suggestions for what

we could do to be even better? 5) Service:

• MrlMrs. _, we like to recognize our employees. Is there anyone you would like to recognize?

6) Appreciation: • We appreciate you taking time thi s morning/afternoon to speak with us about your

care. • Is there anything else I can do for you?

61

Appendix F: Data Collection Template

Database Template (Data Collection)

Age Diagnosis Race Gender LACE # of RN Actions # of Score Admissions Associated Admissions

within 30 with Phone within 31 -60 days call days

(Follow Up Services)

62

Appendix G: Data Collection Template (CHF 0-30 Days)

63

Appendix H: Data Collection Template (CHF 31-60 Days)

Data Templa te

Table 2: Characteristics of 7 CHF patients which received post discharge phone call , b '1 60 d ft d' 1 oy outcome -' - ays a er ISC laro e

Characteri stic Overall Unplanned Readmission 31 -60 days (Patient Variab le) # of NO YES

patients n= (%) n= (%) (%) n=7

Age: 50-60 6 1-70 7 1-80 81-88

Gender:

Female

Male

Race: African American Caucasian Other

LACE Score: <11

2: 11

Follow Up Services Received (coordinated by post discharge ca ll) : MD contacted Patient Education (signs/symptoms) DME Assistance (oxygen) Scheduled Follow up MD Appt Medication Inquiries

Number of Documented Readmi ssions (31-60 days) : 0 1 2 3+

64

Appendix I: Data Collection Template (COPD 0-30 Days)

Data Template

Table 3: Characteristics of7 COPD patients which received post discharge phone call , by outcome 0- 30 days after discharge

Characteristic Overall Unplanned Readmission 0- 30 days (Patient Variable) # of NO YES

patients n= (%) n= (%) (%) n=7

Age: 50-60 61-70 71-80 81-88

Gender:

Female

Male

Race: African American Caucasian Other

LACE Score: <II

" II

Follow Up Services Received: MD contacted Patient Education (signs/symptoms) DME Assistance (oxygen) Scheduled Follow up MD Appt Medication Inquiries

Number of Documented Readmissions (within 30 days): 0 I 2 3+

65

Appendix J: Data Collection Template (COPD 31-60 Days)

Data Template

Table 4: Characteristics of 7 COPD patients which received post discharge phone ca ll , by outcome 3\-60 days after discharge

Characteristic Overall Unplanned Readmi ssion 31- 60 days (Patient Variable) # of NO YES

patients [1 = (%) n~ (%) (%) n=7

Age: 50-60 6 1-70 7 1-80 8 1-88

Gender:

Female

Male

Race: African American Caucas ian Other

LACE Score: <II

2: II

Follow Up Services Received (coordinated by post discharge call) : MD contacted Patient Education (signs/symptoms) DME Assistance (oxygen) Scheduled Follow lip MD Appt Medication Inquiries

Number of Documented Readmi ss ions (31-60 days) : 0 I 2 3+

66

Appendix K: Timeline

#Talk

I Step I: Problem Recognition

10 future Scholmhip Continued E"lualion of Read mils ion @Facility 1

Notes/St'tus

It

complete complcle

ongoing

2012

67

Appendix L: Budget Budget Item Cost Source Computer/Applications $3,500 Provided by facility Workstation (desk/chair) $150.00 Provided by facility RN Reviewer $3400.00* PI as Primary Reviewer SPSS v.20 $110.00 Expense incurred by PI Total Expenses $7160.00 *With PI as primary RN reviewer, the actual cost incurred for this project is $110.00.

68

Appendix M: IRB Approval (Regis University)

REGIS~ UNIVERSITY

October 28, 201 I

Heaven Owens 1409 Schoal Creek Drive St Peters, MO 63366

RE: IRB#: 11-318

Dear Heaven:

Academic Aflalrs Academic Grants

IRB - REGIS UNIVERSITY

3333 Regis Boulevard, H-4 Denver, Colorado 80221- 1099

303-458-4206 303-964+3647 FAX www.regis,edu

Your application to the Regis IRB for your study, "Do post discharge phone calls reduce readmission for Medicare beneficiaries?" was approved as exempt on October 26, 2011.

Supporting reference information from the chair: " ... approved as an exempt study under 45CFR46, 10 I (b)( 4) (review of existing records),

The designation of "exempt," means no further IRB review of this project, as it is currently designed, is needed.

If changes are made in the research plan that significantly alter the involvement of human subjects from that which was approved in the named application, the new research plan must be resubmitted to the Regis IRB for approval.

~ al11dRo;;sd~D. Chair, Institutional Review Board

cc: Dr. Lynn Wimett

A JESUIT UNIVERSITY

69

Appendix N: IRB Approval (Washington University- St. Louis)

ijijWc1shington University in StlDuis Human Resea rch Protection Office

IRS ID #: 201111044

To: Heaven Owens

Bamc!; Jc\\ish HQspilal 51 Louis Children'S Hospital

\'"ashingI0l1 University

From: The Washington University in St. Louis Institutional Review Board , WUSTL DHHS Federalwide Assurance #FWA00002284 BJH DHHS Federalwide Assurance #FWA00002281 SLCH DHHS Federalwide Assurance #FWA00002282

Re: A Descriptive Analysis of the effects post discharge phone ca lls have on readmission rates for Medicare beneficiaries?

Approval Date: 02/15/12

Next IRB Approval Due Before: N/A

Type of Application:

cgJ New Project o Continuing Review D Modification

Type of Application Review:

o Full Board: Meeting Date: o Expedited [SI Exempt o Facilitated

Approved for Populations:

o Children o Prisoners o Pregnant Women , Fetuses, Neonates o Wards of State o Decisionally Impaired

660 South Euclid Ave .. Campus Box 8089. 51 Louis. 1\ 10 631 10 PlIOtltl: (3 J~) 633·7400 FA.-\:: (3 J~) J67·JO~ 1

70

IRB 10#: 201111044 02/15/12 Page 2 of 3

MATERIALS APPROVED

This approval has been electronically signed by IRB Chair or Chair Designee: Erin Wingbermuehle, BA 02/15/121504

71

IRB 10#: 201111044 02/15/12 Page 3 of 3

IRB Approval: IRB approval indicates that this project meets the regulatory requirements for the protection of human subjects. IRB approval does not absolve the principal investigator from complying with other institutional , collegiate , or departmental policies or procedures.

Recruitment/Consent: Your IRB application has been approved for recruitment of subjects not to exceed the number indicated on your application form. If you are using written informed consent, the IRB-approved and stamped Informed Consent Document{s) are available in mylRB. The original signed Informed Consent Document should be placed in your research files. A copy of the Informed Consent Document should be given to the subject. (A copy of the signed Informed Consent Document should be given to the subject if your Consent contains a HIPAA authorization section.)

Continuing Review: Federal regulations require that the IRB re-approve research projects at intervals appropriate to the degree of risk , but no less than once per year. This process is called ~continuing review. ~

Continuing review for non-exempt research is required to occur as long as the research remains active for long-term follow-up of research subjects, even when the research is permanently closed to enrollment of new subjects and all subjects have completed all research-related interventions and to occur when the remaining research activities are limited to collection of private identifiable information. Your project "expires' at midnight on the date indicated on the preceding page ("NextIRB Approval Due on or Before"). You must obtain your next IRB approval of this project by that expiration date. You are responsible for submitting a Continuing Review application in sufficient time for approval before the expiration date, however you will receive reminder notice prior to the expiration date.

Modifications: Any change in this research project or materials must be submitted on a Modification application to the IRB for QdQ.r review and approval, except when a change is necessary to eliminate apparent immediate hazards to subjects. The investigator is required to promptly notify the IRB of any changes made without IRB approval to eliminate apparent immediate hazards to subjects using the Modification/Update Form. Modifications requiring the prior review and approval of the IRB include but are not limited to: changing the protocol or study procedures, changing investigators or funding sources, changing the Informed Consent Document, increasing the anticipated total number of subjects from what was originally approved, or adding any new materials (e.g. , letters to subjects , ads, questionnaires).

Unanticipated Problems Involving Risks: You must promptly report to the IRB any unexpected adverse experience, as defined in the IRB/HRPO policies and procedures, and any other unanticipated problems involving risks to subjects or others. The Reportable Events Form (REF) should be used for reporting to the IRS.

Audits/Record-Keeping: Your research records may be audited at any time during or after the implementation of your project. Federal and University policies require that all research records be maintained for a period of seven (7) years following the close of the research project. For research that involves drugs or devices seeking FDA approval , the research records must be kept for a period of three years after the FDA has taken final action on the mark.eting application , if that is longer than seven years.

Additional Information: Complete information regarding research involving human subjects at Washington University is available in the "Washington University Institutional Review Board Policies and Procedures. " Research investigators are expected to comply with these policies and procedures, and to be familiar with the University's Federa twide Assurance, the Belmont Report, 45CFR46, and other applicable regulations prior to conducting the research. This document and other important information is available on the HRPO website http://hrpohome.wustl .eduf.

72

~\Xashington University in St.Louis Huma n Research Protection Office

IRB 10#: 201111044

To: Heaven Owens

B.1mes Je"ish Hospital SI. Loui sOlildrcn'S Hospi tal

\rashinglon Ullil'ersit y

From: The Washington University in St. Louis Institutional Review Board ,

Re:

WUSTL DHHS Federalwide Assurance #FWA00002284 BJH DHHS Federalwide Assurance #FWA00002281 SLCH DHHS Federalwide Assurance #FWA00002282

A Descriptive Analysis of the effects post discharge phone calls have on readmission rates for Medicare beneficiaries?

Protocol Number: Protocol Version: Protocol Date: Amendment Number/Date(s):

Approva l Date: 02/15112 (Exempt)

This project has been granted a partial waiver of HIPAA Authorization based on the documentation provided by the researcher in the myIRE application Section VII. D and the assurance document signed by the Principal Investigator.

This partial waiver of authorization for recruitment purposes sa ti sfies the following criteria: (I) The use or disclosure of the requested information involves no more than a minimal risk to the privacy of individuals based on, at least, the presence of the following elements: (a) An adequate plan to protect the identifiers from improper use and disclosure (b) An adequate plan to destroy the identifiers at the earliest opportunity consistent with conduct of the research, unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law; and (c) Adequate wri tten assurances that the requested information will not be reused or disclosed to any other person or entity, except as required by law, for authorized oversight of the resea rch study, or for other research for which the use or di sclosure of the requested infonnation would be permitted by the Privacy Rul e; (2) The research could not practicably be conducted without the waiver or alteration; and (3) The research could not practicabl y be conducted without access to and use of the requested information.

This approval has been electronicall y signed by IRE Chair or Chair Designee: Erin Wingbermuehle, SA 02/ 15/ 121 504

660 SQuth Eucl id Ave .. Campus Box 8089. 51 i.olJ is. 1>. 10 63 11 0 Phone: (3 1")6.H·7.fOO FAX: (3 1 .. ) 367·30 .. 1

73

Appendix O: CITI Training

C IT I COII~bor.>tiH Inst lh.li(m;J1 Tr.t.ining Inltl~l;v~

Human RH •• ",h Curri(:ulum Com pol ...... RePOl't Printed on l 1N2011

Lear .... " HEA.VEN OVIE NS (u_ . 5M39:101) 1 .... I~ution : WaSl'W1gIOn U"~!y · 51. LouiIo, MO ConlaCt Emeit 1'1>:021 ~bp::.Otg InfonnatiOil

Group ~ All Otlwr tf_!top Selt<>c:ft MOT L ...... in Group 3:

For , .... Co"'!>lelion RepoR to be VIlle!, the learner "11td ._ mus' be . ffil i.llted wllh. CITI PlRieipollirl{lln'~'ullon. F.leflled Information and u""ulh<Jrlud UN of the CITI coo .... lite Is u .... ' hicel,.nd may be co nslclored .clen~lie misco nduct by your lnatilu!ion .

P ..... B<aoIodI , '\itO ","0 Protessor. ~"of Miamj D_ 0II'w:>e 01 ~"'" ~ CITI Cau .... Coord!nIr.a-

74

Appendix P: Agency Letter of Support

December 15,2011

Heavcn Owens RN, MSN, MBA, TQCI SupelVisor, utilization Review Management Bames-Jewish Hospital St. lou;'. MO 63110

Dear Ms. Owens.

Thank-you for submitting your proposed study entilled. "A Descriptive Analysis of the effects post discharge phone calls have on readmission rates for Medicare beneficiaries"to the Bames-Jewish Hospital Research Council.

This study has undergone both scientific and adminislJative review by the Barnes-Jewish Hospilal Protocol Review Research Cornmiuee.

Your study has been approved.

If you have any questions. please conLaCt me at 454-7274.

Sincerely. /)

P~r~ Patricia A. Porter, RN. PhD. FAAN Director, Department of Research Research Scientist Barnes-Jewish Hospital St. Lou;,. MO 63 141

BARNE3 JEWISH Hospital Iilr!I HealthCare

75

Appendix Q: SWOT Analysis