Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA.
Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
J Gen Intern Med. 2019 Sep;34(9):1815-1824. doi: 10.1007/s11606-019-05082-8. Epub 2019 Jul 3.
Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.
To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.
Quasi-experimental study.
Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.
The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.
Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.
Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).
Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.
许多医疗系统已经实施了基于团队的项目，以改善对高需求、高费用患者从医院到家庭的过渡。虽然初步结果很有希望，但关于最有效的策略的证据有限。
确定强调药物依从性和快速初级保健随访的强化跨学科过渡护理计划对高质量、结果和成本对高需求、高费用医疗补助和医疗保险患者的影响。
准实验研究。
在一个医疗服务不足地区的非营利性医疗保健系统中，在一次住院期间，共有 2235 名高需求、高费用的医疗保险和医疗补助患者被确定为高需求、高费用患者，其中 285 名参与者参加了 SafeMed 护理过渡干预，1950 名作为同期对照。
SafeMed 团队在医院进行实时筛查、患者参与、登记、增强出院护理协调以及至少 45 天的强化家访和电话随访。
主要差异差异分析检查了质量（初级保健就诊和药物依从性）、结果（可预防的急诊就诊和住院、总体急诊就诊、住院、30 天再入院和住院天数）和医疗支出的变化。
调整后的差异差异分析表明，SafeMed 参与与住院人数减少 7%（-0.40；95%置信区间（CI），-0.73 至 -0.06）、30 天再入院减少 31%（-0.34；95% CI，-0.61 至 -0.07）以及 6 个月内医疗支出减少 8690 美元（95% CI，-14441 至 -2939 美元）有关。改善仅限于医疗补助患者，他们的急诊就诊次数大幅减少 39%、住院次数减少 25%、30 天再入院次数减少 79%。药物依从性没有变化（+2.6%；95% CI，-39.1% 至 72.9%）。
强调强化跨学科患者参与和快速初级保健随访的过渡护理模式可以使卫生系统在改善高需求、高费用医疗补助患者的质量和结果的同时降低成本。
