Background
Individuals with multiple chronic conditions require complex care management and often experience significant challenges when transitioning from hospital to home. These transitions are compounded for the nearly 8 million hospitalised individuals, insured by Medicaid who are disproportionately Black, Indigenous, People of Colour (BIPOC) and experience a higher burden of chronic disease and disparities in postacute care outcomes.1–7 In the USA, adults insured by Medicaid have incomes 138% below the Federal Poverty Level (FPL) (roughly $17 800 annually) or up to 155% of the FPL for households.8 They are 15% more likely to be readmitted than privately insured individuals citing significant health-related social needs such as financial stress, high out of pocket medication costs and housing instability.9 10 Compared with individuals insured by Medicare, they are more likely to experience complications and emergency department (ED) visits following hospitalisation, owing in part to foregoing care due to costs and a lack of access to longitudinal community-based care, including specialists.11–15 Postacute outcome disparities experienced by Medicaid-insured individuals are also the result of care occurring during hospitalisation or immediately thereafter. For example, despite substantial evidence linking improved postacute outcomes to care coordination and continuity of care, transitional care practices vary across acute care settings16 with most lacking tailored approaches for patients with multiple chronic conditions and economic disadvantage.17
The lack of comprehensive transitional care support for low-income individuals insured through Medicaid, who are largely BIPOC, represents an example of how healthcare infrastructures, service delivery and the allocation of resources may advantage or disadvantage some groups over others and result in health inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalising conditions such as poverty, that are historically rooted in systemic racism.18 The impact of marginalising conditions is heightened during the period of transition from hospital to home when individuals are required to obtain medications or durable medical equipment, schedule and access follow-up appointments and understand and execute treatment orders all while coping with competing economic needs.19 In addition, low-income, individuals have repeatedly recounted experiences of discrimination based on socioeconomic and racial status during interactions with healthcare providers.20 These experiences may result in avoidance of healthcare settings and paradoxically increase ED utilisation or avoidable hospitalisations due to inadequate management of chronic illnesses.21
Persistent health inequities among Medicaid-insured individuals demand focused innovations that are centred in equity principles and bridge coordination and continuity between acute and community health providers. Such equity-centred innovations may include technology but should also embrace system and process improvements in care delivery.22 From our perspective, equity-centred principles also acknowledge the history of structural inequities that lead to disparate outcomes.23 24 With this understanding, equity-centred interventions must be contextually tailored to address organisational polices, practices and community contexts.
By necessity such interventions should also include stakeholders from diverse backgrounds with intimate knowledge of the local community and healthcare systems. This helps to ensure that the intervention is viewed as meaningful and will be accepted by participants and adopted into clinical workflow. Finally, because inequities experienced by lower status individuals are systemically linked to denied opportunities and resources, innovations that are centred in equity must redirect and or intensify these resources while addressing the health-related social needs requiring attention.
In the following, we present our early results of an innovative clinical pathway developed with a focus on health equity and a goal of supporting a growing population experiencing adverse outcomes, resulting from complex chronic illness, poverty, and structural inequality.
Local problem description
Our healthcare system, Penn Presbyterian Hospital (PPMC), is a Level 1 Trauma centre located in a large city in the Northeast, USA and serves over 300 000 residents of the local community.25 Approximately 75% of individuals on our Medicine Service are Black/African American, 58% are insured by Medicare and 24% are insured by Medicaid.25 26 Results from a study conducted by our team using machine learning and 2017 PPMC discharge data, found that one in five (21%) individuals with Medicaid experienced a readmission within 30-days compared with 6% of commercially insured individuals.27 Similarly, 17% of individuals with Medicaid experienced an ED visit within 30-days of a prior hospitalisation, compared with 4% of commercially insured individuals.15 Finally, the majority of individuals insured by Medicaid were discharged to home without further support, with 20% receiving a home care referral, compared with 31% of adults insured by Medicare and fewer accessing specialty care.27 Results of our single site study were consistent with others showing higher postdischarge utilisation and difficulty accessing postdischarge care among Medicaid insured individuals.4 28
Aware of these disparate outcomes and other challenges following hospitalisation, our interdisciplinary team of clinicians, researchers and community members formed a Working Group with the goal of codeveloping a solution. Using a participatory approach and Human-Centred Design thinking, we codeveloped an intervention to support transitions for low income individuals with multiple chronic conditions.22 29 Participatory activities described, extensively elsewhere, were conducted over the course of 6 months, and included over 80 hours of clinical interviews, 30 inpatient and outpatient observations and 44 stakeholder informal interviews and observations covering eight units in the hospital.22 The culmination of this process resulted in the development of the THRIVE clinical pathway. THRIVE provides 30-day wrap-around transitional care services for individuals with three or more chronic conditions, Medicaid insurance and a Philadelphia zip code.22 27 The goals of the THRIVE clinical pathway are to focus on the physical, social and emotional needs of Medicaid-insured individuals with multiple chronic conditions by providing intensive case management, care coordination, continuity of care and communication across acute and community settings.
Although experts have established evidence-based standards for care transitions, discharge planning and care coordination,30 31 the application of these practices vary across settings and there is limited research on how to tailor discharge support for individuals insured by Medicaid.11 32 The Transitional Care Mode (TCM), for example, emphasises the continuity of care across settings and between providers throughout episodes of acute illness (eg, hospital to home).33 In randomised trials, the TCM has demonstrated reductions in readmission and cost.31 34 However, TCM focuses on older adults and requires additional trained healthcare providers (Advanced Practice Nurses) to coordinate care. Similarly, community health workers (CHWs) have increasingly extended support to individuals following hospitalisation. At least one randomised trial evaluating the use of CHWs demonstrated a reduction in readmissions for individuals with significant social needs. Despite facilitating important links to social services, CHW’s are unable to address clinical needs for medically complex patients in real time.35–37 Similarly, additional studies, by Jackson et al,38 Liss et al39 and Balaban et al,40 describe interventions to address medical and social needs among economically disadvantaged adults. While two of the three interventions appeared to decrease rehospitalisations over the course of 6 months to a year,38 39 none yielded reductions in readmissions and ED use in the critical period of 30 days.
In the current paper, we describe the outcomes of THRIVE participants during the first year including using plan-do-study act (PDSA) cycles. We also report differences in frequency of 30-day readmission and ED utilisation for individuals participating in the THRIVE clinical pathway compared with those that did not. We also describe frequency of referrals to community-based clinical and social services (ie, home care, primary care, specialty care, social workers and CHWs).
Design: THRIVE program description
With THRIVE, individuals are identified by Nurse Case Managers during hospitalisation using a predictive algorithm developed by our team.27 Within 48 hours after discharge, THRIVE enrollees receive a visit from a home care nurse. During home care visits, nurses serve as health coaches and spend time reviewing medications, and discharge orders, completing medication reconciliation and developing person-centred goals of care. THRIVE enrollees receive other clinical care services as warranted, including occupational therapy, physical therapy and social workers during the immediate days following a hospital discharge. THRIVE participants are assessed for social needs and referred to a CHW, as needed, who provides an additional layer of community-based support (figure 1).
The THRIVE clinical pathway. EHR, electronic health record.
Another important aspect of the THRIVE clinical pathway includes the extension of support from the hospital-based discharging physician to patients following discharge. Clinical support from discharging physicians is provided through telephone and electronic health record (EHR) contact with home care nurses at the completion of the first home visit through calls or direct messaging. Nurses raise questions about medications (eg, medications found at home that are not documented in the discharge instructions), request additional medical equipment, clarify discharge orders and address emerging symptoms in real time with the provider who most recently oversaw the individual’s care. Our partnership with discharging physicians in this way is novel and actively works to address acute clinical needs attributed to the recent hospitalisation or to destabilisation of a co-occurring chronic condition in the days following discharge.
Following discharge, the THRIVE teams hosts virtual case conferences with the interdisciplinary team where each THRIVE participant is discussed weekly for 1 month after discharge. A home care Nurse Manager helps to facilitate weekly case conferences by serving as a clinical liaison to the THRIVE team and bringing to the team social and medical concerns that were noted during home care engagement. The THRIVE team is fully empowered to provide a holistic and integrated approach to care by being responsive to our clients’ needs (physical, social and emotional). By centring the health-related social needs of Medicaid patients, we directly address many of the factors that drive health inequities (ie, transportation, housing and food insecurity) by facilitating referrals to community-based resources including CHWs, or assistance with applications to low-cost housing.
