Monday, 17 March 2014

Readmissions (2). What are the experiences that are yielding results?

The Congress Investigation Services of the US (CRS) published in September 2010, in support of the Obamacare, a report on charges for Medicare of hospital readmissions. The very well documented report assumes that 17.6% of discharge bills issued by hospitals to Medicare are due to the readmissions occurred within 30 days of discharge. Therefore, the two economists who signed the report assumed that they found in the readmissions a source for collecting Medicare savings, moreover taking into account that the variations between areas were making it possible to foresee that an adjustment in the contracting model could be fruitful.

From this document I liked the classification of the actions aimed at reducing readmissions, actions that as it will be seen to be effective, must be tailored to the complexity of the elected patients.

Model 1: very complex patient, intensive action

Transitional Care Model

This model is oriented to patients with multiple diagnoses and high risk of readmission. In a clinical trial (Naylor 2004) elderly patients with heart failure and an average of 5 co-morbidities were selected. The intervention consisted of:
  • Nurses with experience of at least two months in working with psycho-geriatric multidisciplinary teams
  • Daily patient visits during the hospital stay
  • Programming at least 8 home visits during the first three months after discharge
  • Telephone availability
Trial results: one year after discharge, the patients to the group intervened had reduced readmissions relative to the control group, to the extent that economists considered the annualized economic balance of the Transitional Care Model was generating savings of 37.6%, after making a balance between the costs of the program on the one hand and the reduction of admissions on the other hand.

Model 2: complex patient, light performance
Care Transitions Intervention

In another clinical trial (Coleman 2006) patients with complex health needs were chosen, but without requiring as extreme criteria as the Naylor test. The intervention consisted of:
  • Nurses with specific training in coaching (with resources to teach patients and families on how to manage the symptoms of disease)
  • Patient visits during the hospital stay
  • Schedule a visit during the first three days after the discharge
  • Scheduling three follow up phone calls
With this program, each nurse can handle a group of 24 to 28 patients, so the authors believe that this model is cheap and easy to apply and, according to the trial, it has significant reductions in readmissions over a period of 180 days. This model hasn’t got a cost study as in the previous one.

The Congress document considers that the light format of the Transitional Care Model is extended to 140 organizations, as in the example of Kaiser Colorado, which has shown that the program has reduced readmissions from 14% to 2.4%, with savings of $4M.

Model 3: complex patient, performance coordination (Spanish experience)

Pre-Alt Program

If I had to categorize the Spanish Pre-Alt program, a program that is implemented with varying degrees of success, in most hospitals, according to the American categorization of the Congress report, I’d define it as "Transitional Care Coordination". The Pre-Alt intervention has the following features:
  • Hospital nurse case managers
  • Identification of susceptible patients and discharge planning at an early stage
  • Notification of the forecasted discharge to the primary care team (usually a nurse) with an advance of 24/48 hours before discharge
  • Essential management to ensure that the patient contacts a professional (usually a nurse) of the primary care team during the first 24/48 hours of discharge
In the Spanish model, with primary care a lot better implemented than in the US, the Pre-Alt program provides coordination links and an understanding that a good transfer between levels is better than the usual lack of coordination. Unfortunately, I can not defend this program with a methodologically sustainable evaluation.


The programs for transferring patients between hospital and home for complex or very complex patients are a valuable part in addressing the chronic and frail. As it’s increasingly and frequently well known for these patients, the current organizational models of health care are a burden that does nothing but worsen clinical outcomes and costs.

The hospitals, until they don’t decide to develop integrated units, must find ways to soften the harmful results of the lack of coordination, therefore, it’s necessary to take note that, implementing transitional programs provides efficiencies in the system, and comfort to patients.

If you want to do a simple test on the degree of coordination in a certain area, just ask a family doctor of that area whether he receives information from the professional side when one of his/her patients are admitted to hospital, and if you want to do a quick test of the accessibility of complex chronic patients to resources tailored to their characteristics, one should ask the patients whether they know what to do when they experience an exacerbation of their usual clinical status, and to call an ambulance and go to the emergency room are not an option.

Naylor MD, Brooten DA, Campbell RL, Maislin F, McCauley KM, Schwartz JS. “Transitional Care of Older Adults Hospitalized With Heart Failure: A Randomized, Controlled Trial” Journal of the American Geriatric Society, vol. 52, no. 5, 2004.
Coleman EA, Parry C, Chalmers S, Min SJ. “The Care Transitions Intervention: Results of a Randomized Controlled Trial” Archives of Internal Medicine, vol. 166, no. 17, 2006.

Jordi Varela


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