Managing Posthospital Care Transitions for Older Adults

Abstract

In this issue of JAMA, Dhalla and colleagues 1 report findings from a randomized trial comparing the effect of usual care vs a "virtual ward" model of posthospital care management for older adults on reducing the primary end point of 30-day hospital readmissions. The virtual ward focused on care coordination by telephone or e-mail contact as well as clinic or home visits for several weeks following hospital discharge. With Medicare hospital reimbursement increasingly tied to 30day readmission rates, this study has potential clinical and financial implications.The study by Dhalla et al was well designed and aimed to test the model described, had successful randomization, targeted a representative group of older patients at high risk of readmission or death, and enrolled approximately 960 patients per group, sufficient to detect reduced hospitalization. The intervention was intended to be scalable using existing hospital resources without substantial investment, specialized training, or role-specific expertise, which was cited as a potential weakness of some published models. The average intervention lasted 35 days with multiple telephone or e-mail contacts (mean, 2.3 per patient), clinic visits (mean, 0.5), and home visits (mean, 2.8) by care coordinators (mean, 1.6), physicians (mean, 0.5), and pharmacists (mean, 0.75). One physician, in an alternating role, was the medical authority on the care team in which the core clinical personnel were care coordinators. It appears, based on the numbers of patients and teams, that a virtual ward had a momentary census of about 30 patients, modestly larger than a typical inpatient service. Despite the coordination of care and direct care provided by the interprofessional team for several weeks after hospital discharge, there were no statistically significant differences between the virtual ward group vs the usual care group in the primary outcome of hospital admission or death within 30 days of discharge (21.2% in the virtual ward group; 24.6% in the usual care group) or in the secondary outcomes of nursing home admission or emergency department visits at 30 days, or in any of these outcomes at 90 days, 6 months, or 1 year.How should these findings reported by Dhalla et al be interpreted in the context of the literature and clinical circumstance of complex patients being discharged from hospitals? Previous smaller randomized clinical trials have reported reductions in rehospitalization for specific groups of patients. In a study by Coleman et al 2 that enrolled 370 per group in 2002 and had nurse practitioners as key agents in managing post-hospital care, 30-day readmissions in the intervention group (8.3%) were re-

Nutritional Vulnerability in Older Adults: A Continuum of Concerns

“…When transitional care is mishandled, the result is often higher levels of complications and likelihood of hospital readmission [73]. Almost one fifth of Medicare patients discharged from a hospital require another hospitalization within 30 days due to an acute medical problem [74].…”

“…Another high-risk situation for older adults occurs when they are receiving transitional care, the care they need when they “move from one care site to another” [72]. When transitional care is mishandled, the result is often higher levels of complications and likelihood of hospital readmission [73]. Almost one fifth of Medicare patients discharged from a hospital require another hospitalization within 30 days due to an acute medical problem [74].…”

Who is High Risk Elderly Patient?

“…In recent years, some studies have suggested that special care programs can be partially effective in reducing re-hospitalizations (37)(38)(39). The striking issue in these studies is that an organization that is applicable to elderly care-related situations, specific to patients with a high risk of complications, does not exist.…”

Receipt of Posthospitalization Care Training Among Medicare Beneficiaries’ Family Caregivers

“…Care transitions are associated with myriad challenges for clinicians and patients. Older adults in particular are at increased risk for medical errors, communication gaps, and unplanned readmission during posthospitalization care transitions . The Centers for Medicare & Medicaid Services has implemented new policies and payment models aimed at improving posthospitalization care transition quality, including the Hospital Readmissions Reduction Program, Bundled Payments for Care Improvement, and transitional care management billing codes…”