The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities
BACKGROUND: Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients.
OBJECTIVE: Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs.
DESIGN: An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015.
SETTING: A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs.
PATIENTS: All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation.
INTERVENTION: The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff.
MEASUREMENT: Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP.
RESULTS: The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting.
CONCLUSIONS: A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.
© 2018 Society of Hospital Medicine
Public reporting of readmission rates on the Nursing Home Compare website is mandated to begin on October 1, 2017, with skilled nursing facilities (SNFs) set to receive a Medicare bonus or penalty beginning a year later.1 The Centers for Medicare & Medicaid Services (CMS) began public reporting of hospitals’ 30-day readmission rates for selected conditions in 2009, and the Patient Protection and Affordable Care Act of 2010 mandated financial penalties for excess readmissions through the Hospital Readmission Reduction Program.2 In response, most hospitals have focused on patients who return home following discharge. Innovative interventions have proven successful, such as the Transitional Care model developed by Naylor and Coleman’s Care Transitions Intervention.3-5 Approximately 20% of Medicare beneficiaries are discharged from hospitals to SNFs, and these patients have higher readmission rates than those discharged home. CMS reported that in 2010, 23.3% of those with an SNF stay were readmitted within 30 days, compared with 18.8% for those with other discharge dispositions.6
Some work has been undertaken in this arena. In 2012, the Center for Medicare and Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office jointly launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.7 This partnership established 7 Enhanced Care and Coordination Provider organizations and was designed to improve care by reducing hospitalizations among long-stay, dual-eligible nursing facility residents at 143 nursing homes in 7 states.8 At the time of the most recent project report, there were mixed results regarding program effects on hospitalizations and spending, with 2 states showing strongly positive patterns, 3 states with reductions that were consistent though not statistically strong, and mixed results in the remaining states. Quality measures did not show any pattern suggesting a program effect.9 Interventions to Reduce Acute Care Transfers (INTERACT) II was a 6-month, collaborative, quality-improvement project implemented in 2009 at 30 nursing homes in 3 states.10 The project evaluation found a statistically significant, 17% decrease in self-reported hospital admissions among the 25 SNFs that completed the intervention, compared with the same 6 months in the prior year. The Cleveland Clinic recently reported favorable results implementing its Connected Care model, which relied on staff physicians and advanced practice professionals to visit patients 4 to 5 times per week and be on call 24/7 at 7 intervention SNFs.11 Through this intervention, it successfully reduced its 30-day hospital readmission rate from SNFs from 28.1% to 21.7% (P < 0.001), and the authors posed the question as to whether its model and results were reproducible in other healthcare systems.
Herein, we report on the results of a collaborative initiative named the Enhanced Care Program (ECP), which offers the services of clinical providers and administrative staff to assist with the care of patients at 8 partner SNFs. The 3 components of ECP (described below) were specifically designed to address commonly recognized gaps and opportunities in routine SNF care. In contrast to the Cleveland Clinic’s Connected Care model (which involved hospital-employed physicians serving as the SNF attendings and excluded patients followed by their own physicians), ECP was designed to integrate into a pluralistic, community model whereby independent physicians continued to follow their own patients at the SNFs. The Connected Care analysis compared participating versus nonparticipating SNFs; both the Connected Care model and the INTERACT II evaluation relied on pre–post comparisons; the CMMI evaluation used a difference-in-differences model to compare the outcomes of the program SNFs with those of a matched comparison group of nonparticipating SNFs. The evaluation of ECP differs from these other initiatives, using a concurrent comparison group of patients discharged to the same SNFs but who were not enrolled in ECP.
