Interest in reducing healthcare costs continues to grow in the national debate on healthcare reform. An important element in this debate is the impact of hospital readmissions on overall healthcare costs. Appropriate discharge planning and transitional case management (TCM) programs are frequently touted in health service literature as potentially successful interventions to improve care and curb cost by reducing or preventing unnecessary readmissions. These programs facilitate care transition from acute care to the home setting, and strive to reduce or prevent unplanned readmissions. Additionally, it has been suggested that program interventions are associated with increased patient satisfaction and overall well-being.¹

Despite tremendous efforts by healthcare providers and hospitals, readmissions are a common occurrence, as many patients experience difficulties in the first few days and weeks after discharge from an acute care facility. Communications among healthcare providers and between providers and patients/caregivers remain inadequate or lacking.² These difficulties commonly result in readmissions to acute care facilities that could have been avoided. Depending on diagnosis, between 5% and 30% of adult medical–surgical patients are readmitted to the hospital within a month.^3-5

Transitional case management programs are expected to reduce preventable hospitalizations by providing a framework for assessing patients’ and caregivers’ understanding of their condition(s) and increasing adherence to their management plan after discharge.⁶ Patients may have problems understanding discharge instructions or adherence to medications. They also may ignore their follow-up appointments with doctors and other healthcare providers. Almost all of these care gaps and barriers are frequently addressed by most TCM programs. It is imperative that healthcare programs engage individuals in their care during this critical time of their illness. Engaging patients or caregivers can occur in many ways, including face-to-face discussions and via telephone or mail.

This study illustrates the impact of a TCM program offered and operated by a national healthcare company. The program proactively monitored and managed hospitalized patients immediately after their discharge to ensure a safe transition to home. Patients identified for this activity were considered high risk for readmission due to their underlying illness, length of hospitalization, or other complex discharge plans.

PROGRAM DESCRIPTION

The TCM program being studied in this analysis was a postdischarge, telephonic, patient-centric program that aimed to close gaps in care for patients after leaving the hospital and returning home. Many patients leave acute care facilities without adequate discharge planning, resulting in unnecessary readmissions. Premature and unnecessary rehospitalizations may result from patients’ failure to schedule outpatient follow-up visits; lack of  follow-up plans with other providers; lack of scheduled necessary laboratory, radiologic, and specialized testing; and absent or inappropriate therapeutic pharmaceutical interventions (such as missing evidence-based therapy, drug duplications, or severe adverse drug reactions).

Case managers used specific tools and assessments to find and then close gaps in care. They discussed with patients their discharge/follow-up plans, including their medications, and assessed their level of functioning (including activities of daily living and cognitive status). Moreover, they conducted a depression screen, safety risk assessment, and caregiver status assessment (if applicable), and identified economic barriers to care such as lack of transportation, caregivers, or personal funds. Case managers educated patients and/or caregivers to increase their understanding of the disease process and facilitated adherence to treatment plans including self-care and other home-based care such as dressing changes and infusions. Lastly, case managers conducted a condition-specific assessment relative to the primary discharge diagnosis (eg, coronary artery disease, cancer, stroke, asthma).

Because it was critical to address potential care gaps in a timely manner to prevent readmission, this TCM process started with 2 attempts by the case manager to contact the patient by telephone within 3 business days of  discharge. If the first call failed to contact the patient, the case manager left a toll-free number and requested a call back. If the case manager did not receive a call back within 2 business days of the first attempt, a second call was attempted. If that failed, the case manager sent an “unable to reach” letter to those who could not be reached. In this letter, the patient was urged to contact the case manager at the toll-free number provided in the letter. The case was left open on the case manager’s list for 15 business days. If the patient was readmitted to the hospital (resulting in an inability to reach the patient), the process was started again after discharge. If the patient did not respond to the letter and did not initiate a contact with the case manager, a third and final call attempt was made. If there was no answer, the case manager left a final message to let the patient know that calls would no longer be forthcoming. The case manager provided a contact number again for future use and then closed the case.

At all times, TCM staff encouraged patients to participate in the program. Case managers used their critical thinking and clinical judgment to identify gaps in care relevant to the disease, current patient condition, discharge instructions, and adherence to care plans. If the patient was not well versed in his or her discharge instructions, the case manager contacted the physician to better understand the discharge instructions and then educated and supported the patient to boost compliance with discharge instructions. For example, after assessing barriers to follow-up care (as mentioned above), the case manager might educate the patient about available options or solutions such as community resources (for financial barriers), the need for making or keeping follow-up appointments with providers, medications gaps, or referrals to other internal or external specialized programs (eg, behavioral health referrals for depression management, cancer or transplant management programs, mail order programs).