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Patient transitions from inpatient to home care are an important area of focus for reducing costly unplanned hospital readmissions. In rural settings, the challenge of reducing unplanned readmissions is amplified by limited access to both ambulatory and acute care as well as high levels of social disadvantage. In addition, there is a scarcity of evidence regarding strategies that have been proven to improve care transitions and related patient outcomes in this setting. This paper describes the process for implementation and results of a telephone-based transitional care management (TCM) program designed to reduce readmissions for patients with diabetes in a rural hospital in Scotland County, North Carolina. Data were collected from July 2016 to January 2019 using billing records to identify adult patients with high or very high risk of readmission based on length of stay, acuity, comorbidity, and emergency department visits (LACE) scores. Care managers contacted eligible patients by phone after discharge to review discharge instructions, assess need for home health services and transportation assistance, and schedule primary care follow-up visits. Overall, 13.8% of 15,271 discharges were targeted for TCM; 68.2% of these involved a patient with diabetes. The post-intervention 30-day readmission rate was 18.0% among patients identified as high or very high risk versus 8.8% among the overall population and did not differ significantly between TCM participants with diabetes and those without (22.9% vs.18.8%; P  = 0.525). Findings highlight challenges with implementing transition of care interventions in rural settings, which include staffing, patient volume, and accessing data from out-of-network providers.

Importance: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking., Objective: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need., Design, Setting, and Participants: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach., Interventions: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days., Main Outcomes and Measures: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use., Results: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03)., Conclusions and Relevance: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs., Trial Registration: ClinicalTrials.gov identifier: NCT03204643.

Background: Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings., Objective: To evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission., Design: A non-blinded, pragmatic randomized controlled trial ( Clinicaltrials.gov : NCT02763202) conducted at two hospitals in Charlotte, North Carolina., Patients: A total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions., Intervention: Random allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941)., Main Measure: Thirty-day, unplanned, inpatient, or observation readmission rate., Key Results: The 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02)., Conclusions: An intervention inclusive of contemporary recommendations does not reduce a high-risk population's 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions., Trial Registry: ClinicalTrials.gov ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202.