A successful hospital-based disease management program to reduce admissions among patients with multiple chronic illnesses
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Abstract:
Objectives : To examine the effect of a hospital-based disease management program in reducing monthly hospital admission rates among patients with multiple chronic illnesses. Design: Interrupted time series analysis. Setting: A public hospital system comprised of three campuses in suburban Melbourne, Australia. Participants: 2,341 patients with three or more chronic illnesses enrolled in a hospital-based disease management program upon discharge. Intervention: Prior to hospital discharge, an inpatient coordinator refers eligible patients to the disease management unit (DMU). A DMU care coordinator invites patients to enroll and immediately schedules a comprehensive hospital-based outpatient clinic visit. The clinic utilizes a patient-centered team approach including a physician trained in multi-specialty care, a pharmacist, and a DMU nurse. Additional clinic visits are scheduled as needed. Between clinic visits, patients receive continued intensive contact with the DMU team, home visits by a pharmacist if necessary and optional patient education classes. The DMU liaises with the patient’s general practitioner throughout the program until the patient is stable. Measurement: Admissions per 1,000 patients per month (PTPM), evaluated 50 months before and 50 months after enrollment in the DMU program. Results: During the 50 month period pre-intervention period, admissions trended significantly upward at a rate of 2.43 admissions PTPM (95% confidence interval = 1.47, 3.38). Admissions PTPM during the 50-month period after enrollment trended significantly downward at a rate of 3.54 admissions PTPM (95% confidence interval = -4.71, -2.37). Conclusion: A comprehensive hospital-based disease management program successfully reduced monthly admissions for complex chronically ill patients during the 50 months following enrollment in the program compared to the prior 50 months. Contrary to many recent disease management evaluations, these findings suggest that it is possible to design a program to effectively reduce admissions, the largest cost driver in a chronically ill population, but that a person-centered closed-loop system involving both inpatient and outpatient services is likely required.Keywords:
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Aim: To assess whether a pilot study conducted in the UK achieved its objective to reduce admissions to hospital and bed days in patients identified as suitable recipients of case management by community matrons. Background: The Department of Health has advocated the use of nurse-led case management to improve the coordination of care and prevent inappropriate hospital admissions. Method: 66 patients and another 66 controls were identified for the ‘Evercare’ caseload according to criteria set by United Healthcare. Admissions data for the 6months after entry into the study were collected from the hospital information system. Findings: Admission rates in both the control and intervention group decreased over time and there was no significant difference in rates between the two groups at 6months. There was no demonstrable effect on length of stay either. Users were satisfied with the service and nurses cited several clinical stories implying benefits for individual patients.
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Inpatient care
Mentally ill
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Respiratory therapist
Disease management
Respiratory care
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Background: In an environment of an ageing population, with patients exhibiting multiple co-morbidities and taking multiple drugs, as well as attending emergency departments with preventable admissions, the project team aimed to implement and evaluate nursing home outreach clinics. Objectives: To demonstrate the benefit of holding consultant pharmacist-led medication review clinics in nursing homes; improve medication appropriateness and assess if a reduction in the number of hospital admissions was achievable. Methods: Patients were reviewed in outreach clinics in the nursing homes. Data on patient age, number of drugs taken and clinical interventions made was collected for all patients seen. Monthly emergency department attendances were tracked and hospital admissions monitored. More detailed data was collected for 100 patients on type and significance of clinical interventions made, medication appropriateness, using the medication appropriateness index (MAI) and drug costs. Results: Over a 12-month period, in 16 homes, 727 patients were reviewed and an average of 2.9 clinical interventions made per patient. Over the project duration, the average number of hospital admissions from these homes dropped from approximately 3.5 to 1.5 per month. Total estimated drug cost savings for the project over a 2-year time period were estimated at £213k. Individual and total MAI scores for 100 patients, evaluated in more detail, showed a highly significant improvement after clinic review (Wilcoxon Signed Rank test, p<0.001), indicative of more appropriate prescribing. Discussion: Nursing home outreach clinics have resulted in cost-effective and safer patient care via significant clinical interventions and increased appropriateness of drugs prescribed for vulnerable older patients with complex needs.
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Background
Many patients with multiple chronic conditions have challenges in understanding, accessing and navigating the healthcare system, leading to frequent ED use, admissions and readmissions. We piloted a planned Community Paramedicine Visit Program (CPVP) to patients at risk for repeated ED visits or admissions, in an effort to reduce hospital utilization in a community safety-net hospital.Objectives
Reduce avoidable hospital use by identifying high-risk patients with patterns of high utilization and referring them to CPVP.Methods
This pilot was conducted in The Bronx, NY with a single EMS agency and a single safety-net hospital, focused on Medicaid patients as part of a NYS Medicaid waiver. Initial challenges of identifying and referring high-risk patients were addressed using PDSA ramps. Analysis looked at hospital use for each of the 43 unique patients referred into the CPVP and compared equal time periods pre- and post-referral for each patient. The analysis does not include patients who refused referral or accepted referral but refused enrollment into CPVP.Results
The cohort had 160 visits to the hospital (inclusive of emergency department visits, admissions and readmissions) in the 1 to 6 months prior to their referral. The same cohort of patients had only 65 hospital visits in the 1 to 6 months after their engagement in the CPVP; this represents a 59.4% reduction in hospital use and a 59.4% decrease in the average number of visits per patient.Conclusions
The Community Paramedicine Visit Program decreased hospital use by high-risk patients. Team-based QI efforts help engage more patients in this valuable program.Cite
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Asthma is the most common chronic condition of childhood, for which morbidity, mortality, and cost are increasing. This study was performed to determine whether patient education and assignment to a primary care provider improve outcomes and cost in the management of pediatric asthma.A prospective pilot study of 61 patients was conducted with a retrospective review. Data were obtained from health and pharmacy records.Sixty-one unassigned pediatric asthma patients who were noted to be frequent users of emergency department services and who had no primary care provider were identified. This cohort received asthma education and was assigned a provider trained in the national asthma guidelines. Hospital admissions, Emergency Department and clinic visits, use of beta 2 agonists and anti-inflammatory drugs, number of chest radiographs, and continuity of care were recorded for a mean of 58.1 months before and 11.2 months after the intervention. A cost analysis was done.All measured parameters showed favorable changes after intervention, with the decrease in the number of prescriptions of monthly inhaled anti-inflammatory drugs and chest radiographs ordered being statistically significant (P = 0.007 and P = 0.040, respectively). Monthly admissions, Emergency Department visits, and clinic visits declined after intervention when evaluated after 22.8 months of follow up. Annual resource savings after intervention was estimated to be $4845.29 per patient for this military hospital.A combined intervention consisting of provider and patient education and assignment to a primary care provider was associated with improved care and economic outcomes in this group.
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Objective To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. Design, setting Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. Participants Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 ‒ 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. Intervention Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. Major outcomes Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. Results By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52‒1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22‒0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48‒0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit‒cost ratio of 31:1. Conclusion A collaborative pharmacist‒GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).
Wedge (geometry)
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The Medicare Hospital Readmissions Reduction Program (MHRRP) which took effect on October 1st, 2012 holds providers accountable for quality of care delivered, placing a greater focus on care coordination. Innovative strategies in medication management in the acute care and outpatient primary care settings require vigilant pharmacist intervention. The objective of this study is to determine if pharmacist-provided medication reconciliation service in conjunction with hospital follow-up outpatient physician visits reduces hospital readmission rate.This was a prospective study in which physician-initiated outpatient hospital follow-up appointment scheduling was used to identify patients at time of hospital discharge. All patients ≥50 years of age were eligible for outpatient pharmacist visits. Emergency room visits were excluded. Data collected included: patient demographics, characteristics of identified drug therapy problems, accuracy of outpatient medication histories and time required by pharmacist to perform the reviews. Patient adherence to early (24-72 hours) outpatient hospital follow-up visit was also evaluated. Previous year's readmission data for high risk patients who received only physician visits were also collected for comparison with those who were jointly visited by pharmacists and physicians.A total of 98 patients were assigned to receive pharmacist intervention in conjunction with physician hospital follow-up visits. Nine of the 98 patients seen by pharmacists at hospital follow-up visits were readmitted (9.2%) to a hospital within 30 days of discharge. Out of the 236 patients seen during the same period the previous year (2011) for physician alone hospital follow-up visits 46 were readmitted (19.4%) within 30-days of hospital discharge. The difference between these groups was statistically significant (p = 0.023), with patients in the pharmacist intervention group experiencing a reduction in 30-day readmission risk. Physician alone outpatient follow-up was associated with earlier mean time to readmission, 12.8 days vs. 18.3 days in the pharmacist intervention group (p = 0.042).Pharmacist involvement in hospital discharge follow-up visits reduced overall readmission rate in high risk patients and improved monitoring of drug therapy, and medication history accuracy when compared to physician-alone visits.
Outpatient clinic
Hospital Readmission
Medication therapy management
Demographics
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Results of a study to determine whether routine use of a multifaceted medication-focused intervention at a safety-net hospital was feasible and could reduce hospital readmissions in a Medicare fee-for-service population are reported.A quality-improvement cohort study of 1,059 admissions of 667 patients at an inner-city hospital was conducted. Patients in the intervention groups received some or all components of the multifaceted "Medication REACH" intervention, with direct pharmacist involvement from admission through postdischarge aftercare. A pharmacist reconciled medications, provided patient-centered education, collaborated with healthcare providers to optimize therapy, ensured access to medications, and followed up with patients at home as needed. Rates of unplanned readmissions within 30 days of discharge in the full- and partial-intervention groups and in patients who received standard discharge care were compared.Among patients who received the full Medication REACH intervention, 30 of 305 admissions (9.8%) resulted in unplanned readmissions within 30 days, as compared with a readmission rate of 20.4% (110 of 538 patients) among patients who received standard discharge care (p < 0.001). Linear regression modeling, with adjustments for patient age, sex, ethnicity, and case-mix index, indicated an adjusted risk difference favoring the full-intervention group of 9.4 percentage points (95% confidence interval, 4.3-14.6 percentage points; p < 0.001).Rates of 30-day readmission were substantially lower with pharmacist involvement and collaboration with other healthcare team members during patient transitions from the hospital to the home setting.
Medication therapy management
Hospital Readmission
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