Transitions from hospitals to the ambulatory setting are high-risk periods for patients. The advent of the patient-centered medical home (PCMH) and accountable care organizations (ACOs) has provided an opportunity for true collaboration in which both inpatient and outpatient providers contribute to improving transitions in care. Few studies have rigorously evaluated real-world, patient-centered interventions that take advantage of these new developments in health care.
The goal of this study was to develop, implement, refine, and evaluate a multifaceted, multidisciplinary transition intervention across 2 hospitals and 18 PCMHs within a Pioneer ACO.
The study population included adult patients admitted to medical or surgical services at 2 hospitals within the Partners ACO, with primary care physicians at the 18 participating PCMHs, and with a plan to be discharged home. We developed an intervention with the following components: inpatient pharmacist-led medication reconciliation and patient counseling, coordination of care and patient education from an inpatient discharge advocate and the PCMH responsible outpatient clinician, a structured visiting nurse intervention, structured postdischarge phone calls, timely follow-up visits, tools to improve communication among care team members, and home pharmacist visits for selected patients. The study used a stepped-wedge design in which each PCMH practice started in the usual care arm and then, at a randomly selected point in time, changed to the intervention. Outcomes included 30-day hospital readmissions using administrative data and telephone follow-up, and new or worsening symptoms in the 30 days after discharge based on telephone follow-up and medical record review. We analyzed the 2 outcomes by multivariable logistic and Poisson regression, respectively, adjusted for study month, season, patient demographics, risk for postdischarge adverse events, inpatient unit, and primary care practice.
We enrolled 1657 patients, including 679 assigned to usual care and 978 to the intervention. Receipt of different components of the intervention varied by component and in some cases by hospital, unit, and practice. Thirty-day nonelective readmission rates were 10.9% in the intervention arm and 11.5% in usual care (adjusted odds ratio [OR], 1.08; 95% CI, 0.64-1.85, = .77). The number of new or worsening symptoms was 0.90 per patient in the intervention arm and 0.92 per patient in usual care (adjusted OR, 0.78; 95% CI, 0.64-0.95; = .01). The intervention was also associated with a 48% relative reduction in postdischarge adverse events (adjusted IRR = 0.52, 95% CI, 0.30-0.91, = .02). A priori subgroup analysis found no evidence for effect modification of the intervention on readmission rates, new or worsening symptoms, or adverse events.
Results showed no difference in adjusted 30-day readmission rates among patients in the 2 study arms, likely owing to lower than expected intervention fidelity and the low proportion of readmissions that are truly preventable in this patient population. However, the intervention was associated with a reduced rate of new or worsening symptoms in the postdischarge period and on postdischarge adverse events—outcomes that are more sensitive to change than readmissions. As with readmissions, efficacy was likely limited by intervention fidelity. Limitations include confounding by indication for some of the intervention components. Further study is needed to explore the causes and effects of low intervention fidelity, to determine the most important components of the intervention, and to explore variation in care by hospital, inpatient unit, and primary care practice.
