A Transitional Care Model for Patients With Acute Coronary Syndrome
Published Online: June 20, 2014
Sherry Bumpus*, PhD, FNP-BC; Barbara L. Brush*, PhD, ANP- BC, FAAN; Susan J. Pressler*, PhD, RN, FAAN; Jack Wheeler, PhD; Kim A. Eagle*, MD; and Melvyn Rubenfire*, MD *These authors contributed equally to this work
It was estimated that 15.4 million Americans suffered from coronary heart disease between 2007 and 2010, and nearly 1 635,000 more would have a new coronary event. Of the latter, 419,100 will likely survive and approximately 67% of those (280,000) will suffer a recurrent event warranting rehospitalization (not including those who will have a silent event).1 Despite these projections, little is known about the circumstances culminating in a hospital readmission for patients with acute coronary syndrome (ACS). Possible contributors, however, have been speculated to include premature discharge, lack of prompt access to cardiology follow-up after hospital discharge,2 insufficient discharge education, lack of patient understanding of education provided, and poor patient and provider adherence to American Heart Association/American College of Cardiology Foundation (AHA/ACCF) guidelines.3 Whatever the cause of these hospital readmissions, especially those deemed avoidable,4 they place a substantial burden on an already stressed US healthcare system.5 To address these high rates of readmission, many clinical scientists and care providers are looking to new models of care that focus specifically on the transition period between hospital discharge and home.
Transitional care begins prior to hospital discharge and terminates once an outpatient care team has seen the patient and assumed care responsibility. Most transitional care models are designed around direct patient assessment, diagnosis, treatment, and education during this interim phase.6-9 This is achieved by facilitating communication among providers, improving discharge education and medication management, resolving outstanding diagnostics, and instructing patients when to seek care.10
Healthcare providers have long recognized the consequences of poor patient follow-up, but lack of provider accountability between discharge and ambulatory care follow-up has allowed a gap in care transitions to go largely unchecked.11 As an example, Jencks and colleagues5 reported that 50.2% of Medicare patients rehospitalized within 30 days of discharge had no record of being seen by a healthcare provider postdischarge. One consequence of such oversight is the rising number of potentially preventable hospital readmissions.12 Initially, the aim of reporting hospital readmission rates was to draw attention to the dilemma and allow patients to make informed choices about where to seek care.13 Later, readmission rates became part of pay-for-performance programs.14 Now, as a result of the Patient Protection and Affordable Care Act (ACA), hospitals with above-average readmission rates will be penalized with a reduction in the percentage of their Medicare reimbursement. Initial fines were imposed in 2013 and levied against 2012 readmission rates.
We developed the Bridging the Discharge Gap Effectively (BRIDGE) program to facilitate timely postdischarge care for patients discharged with a cardiac diagnosis. Operating since 2008, BRIDGE provides a 1-time ambulatory transitional care visit within 14 days of discharge, and stresses the importance of developing trusting relationships between patients and providers.15 The BRIDGE clinic is staffed by 5 specialty-certified cardiovascular nurse practitioners (NPs) who function in colaboration with the discharging cardiologist. The goal of the NPs is to eliminate many of the aforementioned contributors to hospital readmissions by conducting thorough examinations, reviewing diagnostic tests postdischarge, evaluating response to treatment, performing medication reconciliation, making therapeutic adjustments when necessary, and ensuring that appropriate follow-up and referrals are scheduled. The NPs tailor education about the individual’s event, condition, disease process, and signs and symptoms that should trigger a call to a physician or an emergency department visit. The BRIDGE visit functions as an extension of the hospital discharge team, differing from usual care in 3 distinct ways: (1) the BRIDGE clinic ensures that the time between a patient’s hospital discharge to their first outpatient follow-up is no longer than 14 days; (2) the visit with a NP, while providing traditional evaluation and treatment, emphasizes education and support; and (3) patients are seen by NPs who are integrated within the health system and better able to facilitate and coordinate care within that system compared with those external to the system.
This study aimed to measure the effectiveness of the BRIDGE program by comparing the 30-day to 180-day readmission rates for ACS patients who attended BRIDGE with those who chose not to attend in lieu of usual care. Additionally, it aimed to determine whether medication persistence contributed to the readmission rates. It was hypothesized that patients who attended BRIDGE would have lower 30-day readmission rates and superior 6-month medication persistence rates over nonparticipants.
This was a retrospective study using consecutive data (extracted from an electronic medical record) for all patients referred to the BRIDGE program in a deidentified clinical database. The Human Subjects Internal Review Board of the University of Michigan Medical Center approved this study (HUM00035421).
All patients discharged with a diagnosis of ACS (acute myocardial infarction or unstable angina) from the inpatient adult cardiology service between March 30, 2008, and March 30, 2009, were eligible for this study. Referrals were made to the BRIDGE program based on the lack of availability of a cardiology or primary care follow-up appointment within 14 days of discharge. Patients included in the analysis were divided into 2 cohorts: those who were referred and attended (“attenders”) and those who were referred and did not attend (“nonattenders”). Patients were excluded from the study if they became pregnant, sought follow-up outside the institution, or died within 30 days of discharge. The Social Security Death Index was queried for patients lost to follow-up; only the result of this query was recorded.
The study cohort (Figure 1) included 424 patients referred to the BRIDGE program. ACS comprised 25.2% (n = 107) of the diagnoses referred. Patients were further excluded if they died or were rehospitalized prior to their scheduled BRIDGE appointment (n = 9; 8.4%). The final study sample included 80 patients after excluding patients with missing variables (n = 18; 18.4%).
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