Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission

Abstract

BackgroundUnplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective.MethodsA Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks.Results260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001).DiscussionA nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better.Level of evidenceLevel IV.

Socioeconomic disadvantage is associated with greater mortality after high-risk emergency general surgery

“…Interventions aimed at substantially improving surgical outcomes for patients with high levels of socioeconomic disadvantage likely need to be targeted “upstream” from hospital presentation and incorporate improvements in access to primary care, elective surgical evaluation, and adequate insurance coverage as well as social policies that promote paid medical leave, among others 43–45 . Similarly, consideration of “downstream” interventions such as community-based transitional care teams or expanded coverage of home-care services is warranted 46,47 . Multidisciplinary research focused on addressing the needs of patients from disadvantaged communities is urgently needed and will require the involvement of the surgical community to substantially improve EGS outcomes.…”

“…[43][44][45] Similarly, consideration of "downstream" interventions such as community-based transitional care teams or expanded coverage of home-care services is warranted. 46,47 Multidisciplinary research focused on addressing the needs of patients from disadvantaged communities is urgently needed and will require the involvement of the surgical community to substantially improve EGS outcomes.…”

Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service

“…This is the first known examination of CNI utility at the patient level, rather than community (for which it was designed), and our findings suggest that CNI may be a useful patient-level metric to include in discharge planning after hospitalization for trauma. A recent study by Hall et al 9 described the successful implementation of a Trauma Transitional Care Coordination program, which led to a significant decrease in 30-day readmission rates. By identifying patients with specific medically related, injury-related, and social risk factors, it followed a model of well-established programs employed for chronic medical conditions.…”

Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition of care: a qualitative study

“…Although there is a growing body of research about discharge practices for general medicine and elective surgery patients, there is a relative paucity of evidence concerning optimal practices for this transition of care for TACS patients. [10][11][12] Additionally, there are currently few interventions known to improve the discharge transition of care from the patient's perspective. We sought to better understand the challenges in the transition from inpatient to subsequent recovery by conducting semi-structured interviews of experienced clinicians and patients as a necessary first step to develop interventions applicable to this complex, poorly optimized process.…”

“…Although there is a growing body of research about discharge practices for general medicine and elective surgery patients, there is a relative paucity of evidence concerning optimal practices for this transition of care for TACS patients 10–12. Additionally, there are currently few interventions known to improve the discharge transition of care from the patient’s perspective.…”