Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment

Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine
Bjorg ThorsteinsdottirPaul Y Takahashi

Abstract

Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success. To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions. Retrospective cohort. A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013. Midwest primary care practice in an integrated health system. Enrollment in a CTP during acute hospitalization. The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare. The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, r...Continue Reading

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