IHD Journal Watch: Transitional Care Programs

Transitional Care Programs

Objectives—Medicare penalizes hospitals with 30-day readmissions above their expected rates. Hospitals have responded by implementing transitional care interventions; however, there is limited evidence to inform the development of a successful intervention.

Methods—A total of 512 patients hospitalized at 2 community hospitals, with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), were randomly assigned to the intervention (n = 253) or usual care (n = 259). The intervention encompassed a 90-day hospital-based transitional care program. The primary end points were 30- and 90-day all-cause readmissions. Secondary measures included all-cause emergency department (ED) visits and mortality.

Results—On average, study participants were 67 years of age, 57% female, and 70% insured by Medicare. There was no statistical difference between treatment groups on 30-day readmission incidence rates or 90-day readmission incidence rates. Groups also did not differ in ED visit incidence rates at 30 or 90 days. The mortality rate among patients with CHF showed no difference between groups. However, for COPD, mortality at 90 days was lower in the intervention group than in the usual care group.

Conclusions—Stand-alone community hospitals may be unable to prevent readmissions despite the use of comprehensive, evidence-based intervention components that are within their control. Better collaboration between hospitals and community-based providers is needed to ensure continuity of care for discharged patients.

Analysis

This may in fact be the watershed study when it comes to integrating post-acute transitional care. CMS introduced bonuses and penalties for hospitals with high readmission rates for MI, CHF and pneumonia in 2013. Since then many hospitals have had a laser focus on reducing readmissions for these diagnosis codes. This study evaluated the effectiveness of the Coleman Model often used by hospitals to help ensure a safe transition to the home environment. Finding that the ED use and readmission rates for the CHF patients in the study and control groups were not statistically different was not surprising. This is because the researchers admitted they left one component out of the model: home-based interventions. Helping patients safely transition out of the post-acute setting is most successful, as is most healthcare delivery, when it is as close to the patient’s environment as possible.

The authors’ conclusion that it will take a more integration with community-based providers is evident in communities such as Fort Worth, TX; Long Island, NY; and Portland, OR. Hospitals in those communities have experienced reductions in CHF readmissions, and reductions in readmission penalties, in part because of their partnership with providers who can effectively visit patients where they live and be available around the clock to assist the patient if necessary. These hospital systems recognize, and are benefiting financially from, the value of enhancing the post-acute care transition using these types of providers.

The authors concluded that the reduction in 90-day mortality rates for COPD patients may be due to the increased adherence with use of inhaled medications in the study group as a result of the motivational interviewing (MI) techniques used with the intervention group. How much lower could the mortality rate have been had the MI been conducted in the patient’s home setting by community-based providers?

Journal Source: Linden A, Butterworth SW. A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial. Amer J Managed Care, 2014 Oct; 20(10): 783–92.

Nurse Triage Call Types

Introduction—This study examined the distribution of the Medical Priority Dispatch System (MPDS) Chief Complaint protocols and determinant codes assigned by the EMD as eligible for nurse triage, as well as the distribution of the Chief Complaint protocols contained in the Emergency Communications Nurse System (ECNS) secondary nurse triage process, as determined by the emergency communications nurse (ECN). Protocol distribution was also examined by patient gender.

Objective—This study characterized protocol and gender distributions to provide a better understanding of the types of patients and their associated chief complaints that benefit most from a nurse triage service in the 9-1-1 center.

Methods—This study examined retrospective case data from two separate metropolitan 9-1-1 centers in the United States. The study data was a convenience sample, collected from the inception of the ECNS program in each center until the start of the study. The primary outcome measures were the frequency of specific MPDS (Chief Complaint) protocols determined by the EMD for transfer to the ECN, and the frequency of specific ECNS protocols determined by the ECN during caller interaction. A secondary outcome is the gender distribution of patients for cases in the MPDS and in the ECNS.

Results—Of the MPDS protocols sent (by the EMD) to be triaged through the ECNS, the Sick Person and Falls protocols had notably high frequencies. Falls, Abdominal Pain, Back Pain, and Vomiting were overall the most frequently used protocols in the ECNS itself. Female patients were users of the ECNS in significantly greater numbers than males, particularly within the Abdominal Pain and Vomiting chief complaints.

Conclusion—9-1-1 triage of patients in two urban centers yielded a variety of low-acuity complaints that were handled by the ECN. In the MPDS, the five most frequently used protocols made up the vast majority (approximately 87%) of the cases transferred to the ECN, by the EMD. In the ECNS, the six most frequently used protocols made up a substantial portion (approximately 40%) of the cases triaged with those low-acuity complaints.

Analysis

The U.S. healthcare system and its stakeholders are testing innovations designed to meet the IHI’s Triple Aim of improving patient experience, improving population health and reducing cost of healthcare. Several communities have implemented 9-1-1 nurse triage programs using the Priority Solutions ECNS. These programs are carefully designed with local medical control authorities to navigate 9-1-1 callers with low-/no-acuity symptoms to the safest, most appropriate care setting.

These programs have two distinct components. The Advanced Medical Priority Dispatch System (AMPDS) is used to quickly identify time/life-sensitive priority symptoms and guide emergency medical dispatchers (EMDs) through a protocol-based interrogation to classify the caller into any of 32 distinct call types, and then triage these call types using evidence-based criteria to determine the potential severity of the symptoms. Classifications can range from a true time/life-sensitive condition (Echo) to a condition that could benefit from an alternative response (Omega). Protocol 26, the “Sick Person” protocol, is typically considered the “all other” type of protocol, since these callers, because they lack a defined priority complaint such as abdominal or chest pain, do not specifically fall into any of the 31 other protocols. Protocol 26 includes such call types as hiccups, toothaches and rashes (yes, people call 9-1-1 with these complaints!). The finding that a high proportion of calls eligible for the ECNS are protocol 26 calls is not surprising, as these calls can generally be mitigated with alternative resources.

Falls, specifically ground-level falls, generally do not result in significant injuries and are often triaged as Omega responses, eligible for an alternative resource. These patients may benefit from an assessment and evaluation by a healthcare practitioner to determine the genesis of the fall and perhaps an intervention for future fall prevention. This intervention could be environmental (reduction of trip hazards in the home, installation of grab rails, etc.) or clinical (resolution of vertigo, vision correction, etc.). When an ambulance responds to these calls, the paramedics often do not have the training, resources or expertise to refer patients to programs to prevent further falls. The ECNS nursing model may be a more logical model for ensuring these patients are connected to resources available to help prevent future falls.

Abdominal pain, vomiting and back pain 9-1-1 calls are also commonly triaged as Omega when other priority symptoms are absent. These chief complaints are also some of the most frequent complaints of patients presenting to EDs. We encourage continual study of 9-1-1 nurse triage systems to help navigate low/no-acuity 9-1-1 callers to appropriate care settings to demonstrate the safety and effectiveness of this growing healthcare integration model.

Journal Source: Scott G, McQueen J, Fivaz C, Gardett I, Zavadsky M, Richmond N, Clawson J, Olola C. The distribution of 911 triaged call incident types within the emergency communication nurse system. Ann Emerg Dispatch Response, 2014; 2(2): 9–16.