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PCMH Care Coordination Program Cuts Hospital Readmissions

By Jennifer Bresnick

- Providing cooperative, community-based post-discharge care coordination for elderly patients can help to reduce preventable hospital readmissions, finds a study published this month in the American Journal of Managed Care.  Patients aged 60 or older who completed a care coordination program through a patient-centered medical home (PCMH) were also more likely to go longer between hospital readmissions than patients who did not participate in the program.

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With avoidable hospital readmissions costing billions of dollars each year, and elderly patients being highly vulnerable to bouncing back into the hospital after an acute event, the study highlights the importance of patient-centered strategies, such as those promoted by the PCMH model, to ensure a smooth transition between care settings.

The study, conducted by researchers from the University of Michigan, Ann Arbor VA Healthcare System, and St. Louis College of Pharmacy, used clinical analytics to examine more than 19,000 unique patients with more than 31,000 hospitalizations between them.   Transition of care interventions were scheduled for 572 of those patients, while the same number formed a control group.

Patients who were chosen to be scheduled for the intervention program had a readmission rate of 21.2 percent, while the control patients had a hospital readmission rate of just 17.3 percent.  For every 18 patients that completed the program, one hospital readmission was avoided.

The intervention program included a call from a pharmacist within two to four days of hospital discharge and a clinic appointment with a social worker and healthcare provider within one week of leaving the hospital.  During the initial phone call, the pharmacist performed medication reconciliation, discussed the patient’s health status, and ensured that the patient was following his or her medication regimens appropriately.  The follow-up clinic visit with a social worker ensured that the patient was receiving adequate home care, had access to food, transportation, and social support, and assessed the patient’s capacity for self-care.  The medical professional then completed the necessary exams and helped to coordinate additional appointments and referrals.

Nearly half of scheduled patients failed to complete the program, due to a variety of factors including transportation difficulties, unwillingness to see a provider who was not their primary care physician, or discharge to a rehabilitation facility.  Three-hundred and fifty-six patients were scheduled for the intervention but never completed the program.  Among those patients, 97 experienced hospital readmissions within 30 days.

The authors note that reaching patients as soon as possible to schedule in-office visits was a factor in favor of the program’s success.  Operating costs were kept under control by scheduling intervention patients during regular working hours, though staff members were required to commit significant time to calling patients and conducting evaluations.

“Including chart review, coordinating with other care providers, intervention, and documentation, the pharmacist calls take on average 45 minutes per patient, and up to 24 patients were contacted per week,” the study says. “Social worker time ranges from 1 to 8 hours per patient per week. Medical evaluations are scheduled for 30- to 40-minute appointments, and can take an additional 30 minutes or longer to complete.”

For healthcare providers already working under the patient-centered medical home model, the time and effort required to complete these care coordination interventions may already be built into provider workflows.  However, allocating the necessary resources in organizations that do not have patient-centered protocols already in place may be challenging.

“A PCMH-based, post hospital discharge intervention utilizing a clinical pharmacist, social worker, and medical provider may reduce readmission rates among older patients when performed soon after discharge; however, the effectiveness is dependent on completing the intervention,” the study concludes.

“These results are most applicable to a PCMH focused on the care of older patients. Resources to implement a multidisciplinary intervention may not be available in all clinic settings, and the current study is unable to determine if certain elements were more important than others in improving outcomes; future study is necessary. Nonetheless, this serves as an example of how health system resources can be deployed in an efficient manner to provide coordinated and accountable care for patients.”


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