Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial

Holland, Richard; Lenaghan, Elizabeth; Harvey, Ian; Smith, Richard; Shepstone, Lee; Lipp, Alistair; Christou, María; Evans, David C.; Hand, Christopher

doi:10.1136/bmj.38338.674583.ae

Cited by 269 publications

(343 citation statements)

References 18 publications

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“…Several care transition programs have reported increased readmissions of up to 96 %: high-risk inpatients on a psychiatricsubstance abuse unit assigned to a peer mentorship intervention; 41 medically complex Veterans Affairs patients who received intensive primary care support; 42 younger general medicine patients assigned to nurse case managers coordinating outpatient care; 43 and patients with heart failure assigned to a comprehensive treatment program. 44 Explanations for these paradoxical findings included: increased receptiveness to inpatient treatment for long-standing psychiatric disorders; 41 improved provider-patient communication facilitating detection and treatment of undiagnosed medical problems; 4 2 patients better enabled to self-identify concerning symptoms and seek medical care; 42 personnel added to the care team increased complexity, impairing patients' ability to self-care; 45 and patients using the hospital as respite from housing or social problems. 7 Furthermore, other studies have demonstrated that increased outpatient contact (e.g., PN outreach) may be associated with more readmissions, particularly among younger low SES patients, 46,47 suggesting that such patients may need more finely targeted, and possibly more intensive, outpatient care.…”

Section: Discussionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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BACKGROUND: Evidence-based interventions to reduce hospital readmissions may not generalize to resourceconstrained safety-net hospitals. OBJECTIVE: To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN: Randomized controlled trial. PARTICIPANTS: General medicine inpatients having at least one of the following readmission risk factors: (1) age≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS: PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES: The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS: Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS: A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.KEY WORDS: care transitions; continuity of care; health care delivery; patient safety; underserved populations. J Gen Intern Med 30(7):907-15

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Section: Discussionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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“…However, community pharmacy-based studies investigating medication management of home-dwelling elderly are rare. The already published pharmacy studies report on home-based medication reviews aimed at improving the appropriateness of prescribing (7)(8)(9)(10)(11).…”

Section: Introductionmentioning

confidence: 99%

Medication management among home-dwelling older patients with chronic diseases: Possible roles for community pharmacists

Mehuys

Dupond

Petrovic

et al. 2012

The Journal of nutrition, health and aging

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Objective: To describe medication management among home-dwelling older adults. These data should allow us to identify potential problems and to indicate target areas for community pharmacist intervention.Design: Cross-sectional observational study Setting: Community pharmacies (n=86) in Belgium.Participants: Home-dwelling older adults using at least one chronic medicine (n=338).Measurements: Data on drug use were taken from the electronic pharmacy databases, while drug adherence was measured by pill count, self-report and estimation by GP and pharmacist. Drug knowledge and practical drug management capacity were assessed by patient interview and questionnaire, respectively. Results:The study population (n=338) used a median of 5 chronic drugs per patient. Half of our sample (n=169) used psychotropic medication chronically, mainly benzodiazepines. In 100 patients (29.6%) at least one drug-drug interaction of potential clinical significance was observed. The overall mean adherence per patient was very high (98.1%), but 39.6% of individuals was underadherent with at least one medication. Seventy-six % of patients had an acceptable knowledge of the indication for at least 75% of their medication. In nearly 15 % of the study population cognitive impairment was suspected by the Mini-Cog Test. The participants reported several practical problems with drug taking: difficulties with vision (32.0%), blister opening (12.1%), tablet swallowing (14.8%), tablet splitting (29.7% [represents % of patients who have to split tablets]) and distinction between different drug packages (23.4%). Conclusion:This study identified the following aspects of medication management by home-dwelling older adults that could be improved by pharmaceutical care services: (i) assistance of cognitively impaired patients, (ii) management of practical drug taking problems, (iii) DDI screening, (iv) drug adherence, and (v) chronic benzodiazepine use.3

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“…39 A more recent trial of nurse-led, home-based case management following discharge had no impact on readmissions. 40 Home visits by clinical pharmacists in one trial of 872 discharged patients 80 years or older, despite changes in management of 20% of participants, resulted in a 30% increase (P = 0.009) in readmissions, 41 whereas in another trial involving 362 medical patients, no impact on readmissions was noted. 42 One trial reported significantly reduced adverse drug events as a consequence of pharmacist counselling of patients following discharge but no change in readmissions.…”

Section: Post-discharge Home Visits or Telephonic Follow-upmentioning

confidence: 99%

Preventing the rebound: improving care transition in hospital discharge processes

Scott

2010

Aust. Health Review

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Background. Unplanned readmissions of recently discharged patients impose a significant burden on hospitals with limited bed capacity. Deficiencies in discharge processes contribute to such readmissions, which have prompted experimentation with multiple types of peridischarge interventions.Objective. To determine the relative efficacy of peridischarge interventions categorised into two groups: (1) single component interventions (sole or predominant) implemented either before or after discharge; and (2) integrated multicomponent interventions which have pre-and postdischarge elements.Design. Systematic metareview of controlled trials. Data collection. Search of four electronic databases for controlled trials or systematic reviews of trials published between January 1990 and April 2009 that reported effects on readmissions.Data synthesis. Among single-component interventions, only four (intense self-management and transition coaching of high-risk patients and nurse home visits and telephone support of patients with heart failure) were effective in reducing readmissions. Multicomponent interventions that featured early assessment of discharge needs, enhanced patient (and caregiver) education and counselling, and early postdischarge follow-up of high-risk patients were associated with evidence of benefit, especially in populations of older patients and those with heart failure.Conclusion. Peridischarge interventions are highly heterogenous and reported outcomes show considerable variation. However, multicomponent interventions targeted at high-risk populations that include pre-and postdischarge elements seem to be more effective in reducing readmissions than most single-component interventions, which do not span the hospitalcommunity interface.What is known about this topic? Unplanned readmissions within 30 days of hospital discharge are common and may reflect deficiencies in discharge processes. Various peridischarge interventions have been evaluated, mostly single-component interventions that occur either before or after discharge, but failing to yield consistent evidence of benefit in reducing readmissions. More recent trials have assessed multicomponent interventions which involve pre-and postdischarge periods, but no formal review of such studies has been undertaken. What does this paper add? With the exception of intense self-management and transition coaching of high-risk patients, and nurse home visits and telephonic support for patients with heart failure, single-component interventions were ineffective in reducing readmissions. Multicomponent interventions demonstrated evidence of benefit in reducing readmissions by as much as 28%, with best results achieved in populations of older patients and those with heart failure. What are the implications for practitioners and managers? Hospital clinicians and managers should critically review and, where appropriate, modify their current discharge processes in accordance with these findings and negotiate the extra funding and personnel required to allow succ...

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Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial

Cited by 269 publications

References 18 publications

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

Medication management among home-dwelling older patients with chronic diseases: Possible roles for community pharmacists

Preventing the rebound: improving care transition in hospital discharge processes

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