Home Health Care: Nurse–Physician Communication, Patient Severity, and Hospital Readmission

Pesko, Michael F.; Gerber, Linda M.; Peng, Timothy R.; Press, Matthew J.

doi:10.1111/1475-6773.12667

Cited by 44 publications

(44 citation statements)

References 7 publications

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“…Prediction of readmission is critically important to reduce readmissions for home health care patients. The readmission rate is high, around 30-100% among such patients, and greatly impacts the whole health system [3,14]. Those home care patients usually have a certain degree of disability and are quite vulnerable after leaving the hospital; such a significant jump between the hospital and home requires preventive interventions with more insight into patient health at home.…”

Section: Introductionmentioning

confidence: 99%

Assess the Performance and Cost-Effectiveness of LACE and HOSPITAL Re-Admission Prediction Models as a Risk Management Tool for Home Care Patients: An Evaluation Study of a Medical Center Affiliated Home Care Unit in Taiwan

Wang

Chen

et al. 2020

IJERPH

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The LACE index and HOSPITAL score models are the two most commonly used prediction models identifying patients at high risk of readmission with limited information for home care patients. This study compares the effectiveness of these two models in predicting 30-day readmission following acute hospitalization of such patients in Taiwan. A cohort of 57 home care patients were enrolled and followed-up for one year. We compared calibration, discrimination (area under the receiver operating curve, AUC), and net reclassification improvement (NRI) to identify patients at risk of 30-day readmission for both models. Moreover, the cost-effectiveness of the models was evaluated using microsimulation analysis. A total of 22 readmissions occurred after 87 acute hospitalizations during the study period (readmission rate = 25.2%). While the LACE score had poor discrimination (AUC = 0.598, 95% confidence interval (CI) = 0.488-0.702), the HOSPITAL score achieved helpful discrimination (AUC = 0.691, 95% CI = 0.582-0.785). Moreover, the HOSPITAL score had improved the risk prediction in 38.3% of the patients, compared with the LACE index (NRI = 0.383, 95% CI = 0.068-0.697, p = 0.017). Both prediction models effectively reduced readmission rates compared to an attending physician's model (readmission rate reduction: LACE, 39.2%; HOSPITAL, 43.4%; physician, 10.1%; p < 0.001). The HOSPITAL score provides a better prediction of readmission and has potential as a risk management tool for home care patients.

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Section: Introductionmentioning

confidence: 99%

Assess the Performance and Cost-Effectiveness of LACE and HOSPITAL Re-Admission Prediction Models as a Risk Management Tool for Home Care Patients: An Evaluation Study of a Medical Center Affiliated Home Care Unit in Taiwan

Wang

Chen

et al. 2020

IJERPH

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“…10 In another recent study, researchers found that the presence of communication failures between HHC and physicians was associated with a nearly 10% increase in the probability of hospital readmission among high-risk HHC patients with HF. 11 Our study illustrates that unclear accountability and inadequate communication likely contribute to medication errors and suboptimal safety for both HHC nurses and patients, which may in turn contribute to adverse patient outcomes such as readmissions.…”

Section: Discussionmentioning

confidence: 85%

“…10 In addition, communication failures between HHC nurses and physicians have been found to increase the probability of hospital readmission by nearly 10% in high-risk patients with HF who receive HHC at discharge. 11 As a partner in the continuum of care, nurses provide a majority of HHC services and have a critical role in crafting and implementing a patient's plan of care after discharge. 12,13 An evaluation of Medicare home health practices found that nurses completed over 98% of the first HHC visits for Medicare patients.…”

Section: Introductionmentioning

confidence: 99%

“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

Jones

Richard

et al. 2017

J GEN INTERN MED

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In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

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“…Poor communication between community nurse and physician is associated with an increased risk of hospital readmission among high‐risk patients …”

Section: Methodsmentioning

confidence: 99%

Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before‐and‐after study

et al. 2018

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AimsWe evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients.Methods and resultsWe conducted a before‐and‐after study in a tertiary internal medicine department, comparing 3 years of retrospective data (pre‐intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty‐one patients were included and compared with 1441 patients in the pre‐intervention period. Of the 431 patients, 138 received the transition plan while 293 were non‐completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non‐completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non‐completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7–9.1%).ConclusionsA transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.

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Home Health Care: Nurse–Physician Communication, Patient Severity, and Hospital Readmission

Abstract: Poor communication between home health nurses and physicians is associated with an increased risk of hospital readmission among high-risk patients. Efforts to reduce readmissions among this population should consider focusing attention on this factor.

Cited by 44 publications

References 7 publications

Assess the Performance and Cost-Effectiveness of LACE and HOSPITAL Re-Admission Prediction Models as a Risk Management Tool for Home Care Patients: An Evaluation Study of a Medical Center Affiliated Home Care Unit in Taiwan

Assess the Performance and Cost-Effectiveness of LACE and HOSPITAL Re-Admission Prediction Models as a Risk Management Tool for Home Care Patients: An Evaluation Study of a Medical Center Affiliated Home Care Unit in Taiwan

“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before‐and‐after study

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