Potentially Preventable Hospitalizations: MonashWatch telehealth self-reported journeys before and after acute admission

Abstract

Rationale aims and objectives Potentially preventable hospitalizations (PPH) are a challenge. What happens before hospital admission? Are there crucial tipping points before admissions in at-risk cohorts' trajectories? HealthLinksChronicCare (HLCC) hospital risk-prediction algorithms using admission, diagnosis, and lifestyle data identifies at-patients. MW monitors HLCC patients with outbound phone calls using telehealth -the Patient Journey Record System with alerts representing a real-time anticipated risk of PPH. Health Coaches triage and intervene to optimize GP, hospital and community service utilization to reduce the risk of PPH. Aims To describe a time series of telehealth phone calls related to an acute admission (? 10 days) to investigate tipping points in self-reported biopsychosocial environmental concerns (total alerts) and or condition symptoms of concern (red alerts). Methods MW participants had an acute (non-surgical) admission and >44 calls between 23/12/16 -11/10/17. The Patient Journey Record System (PaJR) and Victorian Admitted Episode Data/ Emergency Minimum Dataset provided longitudinal data. Descriptive time series analysis employed Pettitt's homogeneity test to detect 'tipping points' using XLSTAT package. Findings One hundred three patients aged 74 ± 15.4 years, with 59% male and 61% female, provided 764 call records around admission(s) and 22,715 records over 10 months. Total alerts and red alerts were higher in the 10 days before and after admission. Total alerts significantly increased (tipped) at day 3 before hospitalisation persisting until 10 days. Red alerts increased (tipped) 1 day before admission and remained high following discharge. Discussion and Conclusion Self-report in phone calls describe a pre-hospital phase of 'post-hospital syndrome' (PHS), which began at least 10 days before admission and persisted after discharge. Wide-ranging health, psychosocial, and environmental concerns preceded a tipping point into acute symptoms. Telehealth monitoring of biopsychosocial, as well as disease, concerns require further investigation.