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The American Journal of Managed Care October 2015
Scalable Hospital at Home With Virtual Physician Visits: Pilot Study
Wm. Thomas Summerfelt, PhD; Suela Sulo, PhD; Adriane Robinson, RN; David Chess, MD; and Kate Catanzano, ACNP-BC
Health Coaching by Medical Assistants Improves Patients' Chronic Care Experience
David H. Thom, MD, PhD, MPH; Danielle Hessler, PhD; Rachel Willard-Grace, MPH; Denise DeVore, BA; Camille Prado, BA; Thomas Bodenheimer, MD, MPH; and Ellen H. Chen, MD
The Path to Value Through the Use of Holistic Care
Roy A. Beveridge, MD, Chief Medical Officer, Humana
Delivering Value by Focusing on Patient Experience
Paula Chatterjee, MD, MPH; Thomas C. Tsai, MD, MPH; and Ashish K. Jha, MD, MPH
Medication Adherence and Healthcare Disparities: Impact of Statin Co-Payment Reduction
Jennifer Lewey, MD; William H. Shrank, MD, MSHS; Jerry Avorn, MD; Jun Liu, MD, MPH; and Niteesh K. Choudhry, MD, PhD
Integrated Medicare and Medicaid Managed Care and Rehospitalization of Dual Eligibles
Hye-Young Jung, PhD; Amal N. Trivedi, MD, MPH; David C. Grabowski, PhD; and Vincent Mor, PhD
Solutions for Filling Gaps in Accountable Care Measure Sets
Tom Valuck, MD, JD, MHSA; Donna Dugan, PhD, MS; Robert W. Dubois, MD, PhD; Kimberly Westrich, MA; Jerry Penso, MD, MBA; and Mark McClellan, MD, PhD
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The Impact of Kaua'i Care Transition Intervention on Hospital Readmission Rates
Fenfang Li, PhD; Jing Guo, PhD; Audrey Suga-Nakagawa, MPH; Ludvina K. Takahashi, BA; and June Renaud, BEd
Request of Acute Phase Markers in Primary Care in Spain
Maria Salinas, PhD; Maite López-Garrigós, MD; Emilio Flores, PhD; Joaquin Uris, PhD; and Carlos Leiva-Salinas, MD
Antibiotic Use for Viral Acute Respiratory Tract Infections Remains Common
Mark H. Ebell, MD, MS; and Taylor Radke, MPH
Clinician Considerations When Selecting High-Risk Patients for Care Management
Vivian Haime, BS; Clemens Hong, MD, MPH; Laura Mandel, BA; Namita Mohta, MD; Lisa I. Iezzoni, MD, MSc; Timothy G. Ferris, MD, MPH; and Christine Vogeli, PhD
"Meaningful" Clinical Quality Measures for Primary Care Physicians
Cara B. Litvin, MD, MS; Steven M. Ornstein, MD; Andrea M. Wessell, PharmD; and Lynne S. Nemeth, RN, PhD

The Impact of Kaua'i Care Transition Intervention on Hospital Readmission Rates

Fenfang Li, PhD; Jing Guo, PhD; Audrey Suga-Nakagawa, MPH; Ludvina K. Takahashi, BA; and June Renaud, BEd
By enrolling selected high-risk elderly patients into the intervention, then empowering and educating them, this study successfully reduced hospital readmission rates.
Objectives: To evaluate the effects of Kaua’i Care Transition Intervention (KCTI), a patient-centered intervention program, on reducing hospital readmission rates among patients 60 years or older.
Study Design: A prospective quasi-experimental prepost design.
Methods: Hospital admissions data for the year 2010 (January 1 to December 31) served as the baseline data and were used to identify patients at risk of hospital readmission. KCTI was implemented over a 12-month period from April 1, 2012, to March 31, 2013, and 30-day, 60-day, and 1-year readmission rates were assessed for both the intervention and baseline periods. The impact of the intervention was examined by a logistic regression model, controlling for possible patient population differences.
Results: During the intervention period, a total of 269 patients 60 years or older were admitted to the hospital, of which, 58 were referred to the KCTI program. Logistic regression controlling for patients’ primary health insurance, discharge sites, and certain admitting diagnoses (eg, arrhythmias, cellulitis, chronic obstructive pulmonary disease) found that the intervention reduced the 30-day readmission rate by two-thirds (odds ratio [OR], 0.34; P = .003). Readmission rates within 60 days (OR, 0.42; P <.01) and within a year (OR, 0.48; P <.001) during the intervention period were less than half of the baseline rates.
Conclusions: By selecting patients with identified risk factors, then empowering and educating them with the intervention program, this study was successful in reducing hospital readmission rates. This study also demonstrated the value of carefully selecting patients for intervention programs.

Am J Manag Care. 2015;21(10):e560-e566
Take-Away Points
  • This study demonstrated that empowering and educating high-risk elderly patients to effectively manage their health helps reduce the risk of rehospitalization. 
  • By enrolling only patients with identified risk factors, this study was successful in reducing 30-day, 60-day, and 1-year hospital readmission rates. 
  • This study identified, at baseline, multiple diagnoses as risk factors of readmission to be targeted for the intervention, a unique approach compared with most studies, in which a single diagnostic group is usually identified and targeted. 
  • This study demonstrated the value of carefully selecting patients for the intervention programs.
Readmissions currently remain a costly component of Medicare-covered hospital services, accounting for an estimated $17.4 billion of Medicare spending.1 As early as the 1980s, 22% of Medicare patients were readmitted within a 60-day period, costing the system over $8 billion per year, or 24% of Medicare inpatient expenditures.2 More recently, studies have reported readmission rates of more than 50% for specific conditions or when the window for readmission is extended beyond the 60-day period.1,3 For example, Jencks et al reported that 19.6% of Medicare patients in nonmanaged care acute hospital settings were readmitted to the hospital within 30 days, with 34% within 90 days, and more than half (56.1%) within 1 year of discharge.1

Targeting patients at risk for early readmission has been suggested as one way to reduce hospital readmission rates and Medicare expenditures. Risk factors commonly identified for hospital readmissions include measures of health status, certain diagnoses (eg, sickle cell anemia, gangrene, hepatitis, heart failure, acute myocardial infarction, or pneumonia), a history of recent surgery, advanced age, and 5 or more medical comorbidities.3-9 Using Medicare claims data, Arbaje et al found that being unmarried, living alone, lacking self-management skills, and having an unmet activity of daily living all increased the risk of readmission.10 The term “social instability,” which reflects a relative lack of social support, education, economic stability, access to care, and safety in the patient’s post discharge environment, is an important mediator of readmission risk.9-12

Several different types of interventions have been tested in the field to determine the possibility of reducing both the likelihood and the number of readmissions among older patients. These endeavors can be characterized as being on a continuum from clinical and medical interventions to social and educational efforts.13-19 Among them, the Care Transition Intervention (CTI), also known as the “Coleman Model,” has shown promising results in reducing hospital readmissions both in randomized trials and in real-world open healthcare delivery systems.15,16 CTI is a patient-centered intervention that focuses on empowering high-risk patients to better manage their illnesses through a home visit and telephone calls by trained transition coaches.15,20

Based on the promising findings from CTI, the County of Kaua’i Agency on Elderly Affairs (KAEA), in partnership with Kaua’i Veterans Memorial Hospital (KVMH), initiated the Kaua’i Care Transition Intervention (KCTI) in 2012. The goal of the program, implemented over a 12-month period from April 1, 2012, to March 31, 2013, was to empower and educate high-risk elderly patients to effectively manage their health; to streamline, align, and coordinate home- and community-based services to support aging in place; and ultimately, to reduce hospital readmissions. We hypothesized that the KCTI program would reduce the facilitywide, all-cause 30-day readmission rate at KVMH, as well as reduce all-cause 60-day and 1-year readmission rates there.

KVMH is a general medical and surgical hospital with 45 beds, including 15 acute and 30 acute/skilled nursing facility (SNF) swing and intermediate-care facility (ICF) beds. Its patient population is mainly composed of people aged 60 years and older who reside in West Kaua’i in the state of Hawaii. The total population of Kaua’i was 67,091 in 2010, of which about 15% were 65 years or older.21

Inclusion and Exclusion Criteria

Baseline preliminary analysis of hospital admission data for patients 60 years or older in the year 2010 identified several high-risk groups of patients. These included patients with severe respiratory/pulmonary diseases (ie, chronic obstructive pulmonary disease [COPD], pneumonia), cardiac-related diseases (ie, arrhythmia/congestive heart failure), sepsis, and cellulitis. Patients discharged or transferred to SNF, ICF, or other acute hospitals were also associated with an increased likelihood of readmission compared with patients discharged to home. Those risk factors therefore served as selection criteria for patients to be referred to the KCTI program.

To be enrolled into the KCTI program, a patient needed to be 60 years or older and present with 1 or more of the following admitting diagnoses: 1) severe respiratory/pulmonary disease, 2) cardiac-related disease, 3) sepsis, or 4) cellulitis.

Conversely, several groups of patients were specifically excluded from the study, including: 1) cognitively impaired patients who lacked a primary caregiver, 2) active substance abusers not in a treatment or recovery program, 3) patients with acute mental illness, and 4) long-term nursing home residents.

The KCTI Program

The KCTI program was a 4-week-long intervention that utilized a trained coach (a board-certified occupational therapist) who followed patients upon discharge from the hospital. Referrals to the program were made by a physician or any member of the hospital multidisciplinary team and were coordinated by the hospital social services department.

Initial patient–coach contacts were made in the hospital. The first home visit generally occurred within 24 to 72 hours after discharge. Both the patient and the caregiver received the coaching if the caregiver was available. During this visit, the coach reviewed the patient’s discharge plan and ensured that they were adhering to the treatment protocol, complying with medication instructions, scheduling follow-up appointments with their primary care physician, and attuned to recognize warning signs and symptoms of worsening conditions. As part of this process, the patient received a personal health record (PHR) on which to record their medical history, medications, and allergies. They were encouraged to bring this record to future physician office visits so they could record any updates of their medical information. The coach also roleplayed effective communication strategies with the patient to prepare them to clearly articulate their needs to their primary physician or other healthcare professionals.

After the initial home visit, the coach telephoned once a week to monitor the patient’s progress and address any questions or concerns. The coach also referred patients, if interested, to the KAEA or other agencies for an array of home- and community-based programs that might further assist their home care. Overall, the care transition program followed the patient for up to 4 weeks with 3 telephone calls. If they wished, patients could also initiate contact with the coach. There was a 1-month follow-up mailed client survey. Patients readmitted within 30 days were referred back to the program.

Data Sources

Hospital data for fiscal year 2010 were used as baseline data to examine risk factors associated with readmission. Data from the intervention period, April 1, 2012, to March 31, 2013, were used to examine whether the intervention was able to reduce hospital readmission rates. Only patients 60 years or older were included in the analysis. Whether a patient was readmitted within 30 days, 60 days, or 1 year was determined by the interval in days between the patient’s index discharge date and first readmission date during the intervention period. Although a patient can be readmitted more than once, only the first readmission during the intervention period was used. Only admissions to acute beds, including those in the medical, surgical, or intensive care units, were considered for the determination of whether a patient was readmitted and the total number of admissions. Transfers of patients from acute beds to SNF or ICF beds were not considered as meeting the definition of readmission.

Other variables examined included length of stay, sex, types of admitting medical services, age at admission, patient’s primary insurance, discharge site, and primary, secondary, and tertiary diagnosis. Patient’s primary insurance was reduced to 4 categories: Hawaii Medical Service Association (HMSA), Medicare, HMSA/65C+, and other (all other private insurances available in Hawaii [eg, Alohacare Advantage, Ohana/Wellcare Medicare Advantage Plan]). HMSA is the largest insurance company, providing medical insurance for more than 80% of Hawaiian residents. Discharge sites were reduced into 3 categories: home (with or without home health), skilled nursing facility (including swing beds and ICF placement), and all other sites (eg, other acute hospitals). Due to the small number of patients with COPD or cellulitis as the primary admitting diagnosis, the presence of these 2 conditions among the first 3 admitting diagnoses were used instead.

Statistical Analysis: Primary Outcomes of Hospital Readmission Rates

Chi-squared test or independent t test were used to describe patient characteristics, including mean age of patients, average length of stay, major types of admitting medical services, discharging sites, and primary health insurance. Frequency counts of patients’ primary, secondary, and tertiary admitting diagnoses were provided. Number of referrals to the intervention program and number of patients completing the program were provided.

Chi-squared tests were initially used to evaluate whether readmission rates within 30 days, 60 days, or 1 year differed significantly between intervention period and baseline. To verify that any observed difference in the readmission rates between the intervention period and baseline was due to the intervention rather than other factors (eg, patient characteristics), χ2 tests were used to compare categorical patient characteristics between the 2 time periods, including patient’s sex, discharge sites, patient’s primary insurance, and admitting medical services. Independent t tests were used to compare patient characteristics such as age and length of stay. If the hospital patient populations were found to differ significantly between baseline and the intervention period on any of those characteristics, a logistic regression model was then used to evaluate the effectiveness of the intervention while controlling for those patient characteristics.

Overall quality of the KCTI program was evaluated by the 3-item Care Transition Measure. Responses to each of the 3 questions are scored on a 4-point Likert Scale: total scores are the sum of the responses across those 3 items, with lower scores indicating a poorer quality transition and higher scores indicating a better transition.22

Patient Characteristics

During the intervention period, 269 patients 60 years or older were admitted to the hospital, of whom, 58 were referred to the KCTI program. The age of the study population ranged from 60 to 105 years, with the mean being 78 years. Slightly more than half (51%) of the sample were male. Eighty-nine percent of the patients received medical services, with another 9% receiving intensive care services and 2% receiving surgery or emergency services. Health insurance status included 41% of patients insured by Medicare, 23% insured by HMSA/65C+, and 11% insured by HMSA itself, with the rest of patients insured by 23 other insurance plans (Table 1).

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