The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial
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BACKGROUND: Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.
OBJECTIVES: To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.
DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).
INTERVENTIONS: Multicomponent intervention in the 30 days following hospitalization, including: inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient “discharge advocate” and a primary care “responsible outpatient clinician,” postdischarge phone calls, and postdischarge primary care visit.
MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.
RESULTS: Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.
CONCLUSION: A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.
© 2021 Society of Hospital Medicine
Transitions from the hospital to the ambulatory setting are high-risk periods for patients in terms of adverse events, poor clinical outcomes, and readmission. Processes of care during care transitions are suboptimal, including poor communication among inpatient providers, patients, and ambulatory providers1,2; suboptimal communication of postdischarge plans of care to patients and their ability to carry out these plans3; medication discrepancies and nonadherence after discharge4; and lack of timely follow-up with ambulatory providers.5 Healthcare organizations continue to struggle with the question of which interventions to implement and how best to implement them.
Interventions to improve care transitions typically focus on readmission rates, but some studies have focused on postdischarge adverse events, defined as injuries in the 30 days after discharge caused by medical management rather than underlying disease processes.2 These adverse events cause psychological distress, out-of-pocket expenses, decreases in functional status, and caregiver burden. An estimated 20% of hospitalized patients suffer a postdischarge adverse event.1,2 Approximately two-thirds of these may be preventable or ameliorable.
The advent of Accountable Care Organizations (ACOs), defined as “groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their patients,” creates an opportunity for improvements in patient safety during care transitions.6 Another opportunity has been the advent of Patient-Centered Medical Homes (PCMH), consisting of patient-oriented, comprehensive, team-based primary care enhanced by health information technology and population-based disease management tools.7,8 In theory, a hospital-PCMH collaboration within an ACO can improve transitional interventions since optimal communication and collaboration are more likely when both inpatient and primary care providers (PCPs) share infrastructure and are similarly incentivized. The objectives of this study were to design and implement a collaborative hospital-PCMH care transitions intervention within an ACO and evaluate its effects.
