A program designed to schedule follow-up appointments with primary care practices within 7 days of hospital discharge was associated with fewer readmissions.
Hospitalizations in the United States cost $381 billion in 2012 with 8% of patients readmitted within 30 days of discharge, which cost an additional $16 billion in annual healthcare costs. Previous research has estimated that 1 in 4 of these subsequent visits could have been prevented by utilizing postdischarge follow-up appointments.
A new study in JAMA Network Open observes a program designed to determine whether follow-up appointments with primary care practices within 7 days of hospital discharge (referred to as the 7-Day Pledge) could deter hospital readmission. Strategies of postdischarge follow-up include patient education, medication reconciliation, and a discharge plan review could be used to improve quality of care and lower the risk of patient readmission.
The Camden Coalition was provided with monthly lists of Medicaid patients assigned to primary care offices in Camden by UnitedHealthcare and Horizon NJ Health. These lists were uploaded into the Camden Coalition Health Information Exchange (HIE), which contained daily admit—discharge–transfer data from 4 regional healthcare systems. After these lists were connected to the Camden Coalition HIE, data regarding all admissions was created and placed into a client tracking database. Program staff then used these lists to contact admitted patients in-person or by telephone to schedule a primary care appointment within 7 days of predicted discharge.
The study examined data regarding hospital readmissions from Medicaid patients 18 years or older treated from January 1, 2014, to April 30, 2016, in Camden, New Jersey. Of the 2580 recorded hospitalizations found on patient lists, 1531 records, categorized by timing of follow-up appointments with a primary care practice, were studied after discharge. Types of admissions that were excluded from the program included those that were pregnancy, oncology, and surgery related, those following car accidents, those concerning patients discharged to long- or short-term care facilities who were enrolled in Camden Coalition’s intensive care management program, and those that were exclusively psychiatric because a primary care was visit not determined to be the most beneficial form of follow-up care.
Patients were classified into treatment (n = 450) and nontreatment (n = 1081) groups based on attendance of a follow-up visit with a primary care provider within specific periods of time after discharge. There were 450 (29.4%) discharges with a primary care visit taking place within 7 days, 607 (39.6%) with a visit within 14 days, and 924 (60.4%) discharges with no postdischarge follow-up after 14 days.
In the treatment group, 57 patients (12.7%) were readmitted to a hospital within 30 days compared with 78.8 (17.5%) among the nontreatment group. In the 90 days after discharge, 126 hospitalizations (28.0%) in the treatment group were followed by a readmission compared with 174 (38.7%) for the nontreatment group. This data suggests that follow-up appointments with primary care practices shortly after discharge have a dramatic effect on the likelihood of readmission.
With CMS’ Hospital Readmissions Reduction Program, created by the Affordable Care Act, tying payments to hospital readmission rates, there is more incentive for hospitals to reduce avoidable readmissions. The 7-Day Pledge was found to be successful in determining whether follow-up appointments with primary care practices could deter hospital readmission 7 days after patients were discharged.
“Our care team has always seen the difference it makes when patients visit their primary care providers soon after discharge, and now we have solid evidence that this approach reduces hospital utilization,” Camden Coalition’s chief executive officer Kathleen Noonan, said in a statement. “We’re especially proud of the coalition of hospitals, primary care providers, and community members who contributed to the project. These results show not only the importance of a 7-day follow-up, but also the power of collaboration.”
Another intention of the 7-Day Pledge program was to evaluate whether the total cost of Medicaid could be lowered as hospital readmissions decline. Camden, New Jersey, was chosen as the location of this study due to the fact that the total number of the city’s residents covered by Medicaid vastly exceeded the national average (57% opposed to 20%). The study was orchestrated by the Camden Coalition of Healthcare Providers, which included a total of 12 primary care practices and utilized a citywide data pool.
Financial and health-related incentives were used to motivate hospitalized residents of Camden to participate in the study. Trained teams of healthcare professionals informed patients about the benefits of postdischarge care and encouraged them to attend follow-up appointments within 7 days after their discharge date. Incentives provided for patients included transportation to and from primary care offices and a $20 gift card. Practices were also awarded payments of $100 for visits made within 14 days and $150 for those within 7 in order to prioritize care for recently discharged patients.
The 7-Day Pledge has proven to be proficient in reducing readmission risks and subsequently lowering the total cost of Medicaid. While implementing similar programs can be costly and inefficient to begin, the financial savings accrued over an extended period of time is sure to provide a substantial return on the overall investment.
“Although the study design precluded a more robust analysis of return on investment, a simple analysis of costs and an estimated $10,300 in cost savings per avoided hospitalization suggest that the program would break even if 27 inpatient admissions were avoided annually by connecting 208 patients to primary care within 7 days of hospital discharge,” the authors wrote.
In the future, programs such as the 7-Day Pledge can prove even more successful by targeting patients who are believed to benefit the most from a prompt postdischarge appointment.
“These results are extremely encouraging for our primary care providers working every day to improve the health and wellbeing of the people of Camden,” said Mark Angelo, MD, FACP, medical director of Population Health at Cooper University Health Care, which operates 3 of the practices that took the 7-Day Pledge.
Wiest D, Yang Q, Wilson C, Dravid N. Outcomes of a citywide campaign to reduce Medicaid hospital readmissions with connection to primary care within 7 days of hospital discharge. JAMA Netw Open. 2019;2(1):e187369. doi:10.1001/jamanetworkopen.2018.7369.