A Program To Assist Transitions from Hospital to Home

Introduction: In the US, 1 in 4 heart failure (HF) patients is readmitted to the hospital within 30-days of discharge and the cost to Medicare is billions of dollars annually. This has made reducing readmissions a top priority for Medicare. In July 2012, we implemented the TransitionAdvantage (TA) service at 3 hospitals in central North Carolina. The service is designed to reduce readmissions for HF patients by: 1) assigning patients to transition liaisons (TLs) who have been trained in motivational interviewing to facilitate compliance with discharge instructions and 2) using home telemonitoring to closely follow patients’ medical condition after discharge. A focal point of the service is a technology platform that facilitates information flow during care transitions (Figure). Patients’ discharge instructions are uploaded from each hospital’s electronic medical record and stored on the platform which is used by TLs to help with medication adherence and timely follow-up with doctor visits. Post discharge, patients perform daily health checks of their weights, blood pressures and symptoms. This information is uploaded to the platform via interactive voice response (IVR), web or phone call from TLs, and used by TLs to transfer patients to the nurse phone service if patients show early signs of worsening HF. TLs also facilitate the transfer of discharge summaries to patients’ primary care doctors.Methods:We conducted an interim analysis of the impact the TA service has on 30-day readmission using matched historical controls from the 3 hospitals. We used multivariate logistic regression and adjusted the effect of the TA service for differences between the 2 study groups. We also analyzed surveys of patients and their caregivers regarding satisfaction with the service. We anticipate enrolling a total of 320 patients by study’s end (May 31, 2013). This interim analysis describes results for the first 125 patients enrolled in the TA service. Results: The average patient age was 65 years, 53% were women, and 58% were Caucasian. In multivariate analyses, patients in the TA service were 29% less likely to be readmitted within 30-days of hospital discharge (OR50.71, p50.36). It should be noted that the interim analysis was not powered to demonstrate statistical significance. Patient and caregiver satisfaction with the service was high (95% and 90%; respectively). Conclusion: An interim analysis of the TA service suggests a trend towards lower 30 day hospital readmission and high patient and caregiver satisfaction with the services provided. Final results are expected in late2013.