Academic journal article Care Management Journals

Outcomes of the Maryland Person-Centered Hospital Discharge Program: A Pilot Targeting Decreasing Long-Term Care Use and Hospital Readmissions

Academic journal article Care Management Journals

Outcomes of the Maryland Person-Centered Hospital Discharge Program: A Pilot Targeting Decreasing Long-Term Care Use and Hospital Readmissions

Article excerpt

The Person-Centered Hospital Discharge Program (PCHDP) was offered by the Centers for Medicare and Medicaid Services as a way to improve care to Medicare and Medicaid beneficiaries in Maryland. The PCHDP used a care nurse/coordinator to facilitate the successful transition of patients at risk for becoming eligible for Medicaid. The purpose of this study was to examine the outcomes of the PCHDP pilot, explore factors that influenced hospital and long-term care admissions following hospital discharge, and obtain operational data to develop new programs with related objectives. Area Agencies on Aging were provided with a care coordinator who obtained patient data, developed an individualized care plan, and determined visit frequency and length of services. Multivariate analysis of variance was conducted to examine differences between those hospitalized or admitted to a skilled nursing facility during the follow-up period. The sample consisted of 359 at-risk patients, and the mean length of follow-up was approximately two months. Most patients did not go to the emergency room (N =319, 88%) during the period of follow-up and were not admitted to an acute care setting (N = 301, 84%) or skilled nursing home (N = 322, 86%). Those who were rehospitalized were slightly younger and had more visits from the care coordinator. We anticipate that the care coordinators identified individuals at greatest need for follow-up and support. Future research should explore ways in which these care coordinators can intervene to prevent hospital readmission and long-term nursing home care.

Keywords: transitional care; transitional care program; avoidable hospital readmissions; transitional care nurse; pilot program; discharge program

The transitional care received by older adults transferring between care settings is frequently fragmented and complex, leading to poor quality-related outcomes and higher health care costs (Coleman, 2003; Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). Transitional care is defined as actions and processes to safeguard the coordination of care as patients move and relocate between various settings and/or levels of care between hospitals, patient homes, long-term care facilities, subacute nursing facilities, and primary and specialty care offices (Coleman, 2003). Deficits during these transitions from lack of coordination between providers and settings leave patients and their caregivers vulnerable and inadequately prepared to function autonomously in their least restrictive setting (Levine, Halper, Peist, & Gould, 2010). This may result in readmission to the hospital or admission into a long-term care facility.

Of major concern during the transition process is the potential risk of rehospitalizations, particularly rehospitalizations related to the same problem for which the individual was initially hospitalized. In an analysis of Medicare claims of beneficiaries discharged from 4,926 hospitals in a 12-month period, it was noted that there was a 19.6% hospital readmission rate within 30 days of discharge. The most frequent causes for rehospitalization were heart failure and pneumonia, respectively. The rate of rehospitalization in Maryland in this study population was the highest of all states in the United States at 22% (Jencks, Williams, & Coleman, 2009). The cost implication of these hospitalizations is of particular concern because it has been estimated that $25 billion are spent annually on preventable hospital readmissions (PricewaterhouseCoopers' Health Research Institute, 2010). As of October 1, 2012, under the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is required to reduce payments to hospitals with high readmission rates, specifically, readmission to a hospital within 30 days of discharge from the same or another hospital for conditions of acute myocardial infarction, heart failure, and pneumonia (CMS, 2013). Reducing hospital readmission rates, therefore, is a major focus of the U. …

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