Improving Outcomes After Hospitalization: A Prospective Observational Multicenter Evaluation of Care Coordination Strategies for Reducing 30-Day Readmissions to Maryland Hospitals

Abstract

PAL and TG care coordination interventions were associated with lower rates of 30-day readmission. Our findings underscore the importance of determining the appropriate intervention for the hardest-to-reach patients, who are also at the highest risk of being readmitted.

Does Scheduling a Postdischarge Visit with a Primary Care Physician Increase Rates of Follow-up and Decrease Readmissions?

“…25,26 Moreover, the impact of interventions may only be seen among the highest-risk populations, and ongoing work by others seeks to identify these patients. 27 Regardless of the impact on readmissions, it is important to acknowledge that early PCP follow-up offers many potential benefits. Continuing to evaluate and treat new diagnoses, adjusting and reconciling medications, reconnecting with outpatient providers, capturing new incidental findings, and ensuring stability through regular follow-up are just a few of the potential benefits.…”

Clinical outcomes in patients admitted to a hospitalist service exposed to an antimicrobial stewardship program – a retrospective matched cohort study

“…At the very least, these findings provide reassurance that the PAF did not contribute to adverse outcomes. Patients with a higher Charlson Comorbidity score may be expected to be associated with the composite endpoint more often as a greater number of comorbidities are generally found in sicker patients who would be more likely to die or need frequent hospital admissions [15, 23]. It is important to note that the exposed cohort had a greater quantity of patients with a Charlson comorbidity score of 0 (72.4%) compared to the unexposed cohort (61.3%).…”

Corrie Health Digital Platform for Self-Management in Secondary Prevention After Acute Myocardial Infarction

“…Hospitalization characteristics include the following: (a) hospital admitted to, (b) diagnosis of STEMI or NSTEMI, (c) length of stay, (d) type of intervention received (percutaneous coronary intervention or coronary artery bypass surgery), (e) a count of AHRQ identified Elixhauser comorbidities based on ICD-9-CM and ICD-10 diagnosis codes, (f) discharge disposition, and (g) for patients admitted to JHH and JHBMC, the Health Services Cost Review Commission expected readmission rate, defined by All-Patient-Refined Diagnosis-Related Group (APR-DRG) and severity-of-illness (SOI) combinations. [32][33][34][35] Among participants in the Corrie group, the following potential predictors of engagement with Corrie are being collected at baseline: whether a participant is enrolled with a personal device or iShare, mHealth literacy, and the perceived value of Corrie to help participants achieve their heart attack recovery goals. mHealth literacy is being measured using the mHealth Apps' Trialability and mHealth Literacy five-point Likert scale to assess participants' ability to use mobile devices to seek, find, understand, appraise, and apply health information to address or solve a health problem.…”