Background Improving transitions in care is a major focus of healthcare planning. The objective of this study was to determine the improvement in transitions from an intervention identifying complex older adult patients in acute care and supporting their discharge into the community.
Methods This was a quality assurance study evaluating an intervention on high-risk patients admitted in an acute care hospital. In phase 1, the Length of Stay, Acuity of the Admission, Charlson Comorbidity Index Score, and Emergency Department Use (LACE Index) was selected to assess a patient’s risk for readmission and a standard discharge protocol was developed. In phase 2, the intervention was implemented: (1) all patients were screened for the risk of readmission using the LACE Index; and (2) the high-risk patients were provided care coordination including follow-up phone calls focused on medications, equipment and homecare services. Emergency department (ED) revisits and hospital readmissions were measured.
Results The LACE Index identified 433/1621 (27%) patients at high risk for readmission. Care coordination was achieved within 72 hours in 79% of patients. The 433 high-risk patients receiving the intervention, compared with a group without intervention (n=231), had lower lengths of stay (12.7 days vs 16.6 days); similar 7-day ED revisits (10.6% vs 10.8%) and 30-day ED revisits (30.5% vs 33.3%); lower 90-day readmissions (39.3% vs 44.6%); and lower 6-month readmissions (50.9% vs 58.4%). The 7-day and 30-day readmissions were similar in both groups.
Conclusions Identifying complex patients at high risk for readmission and supporting them during transitions from acute care to home potentially decreases lengths of hospital stay and prevents short-term ED revisits and long-term readmissions.
- health services research
- patient discharge
- transitions in care
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Contributors LC and LJ contributed substantially to the conception and design, acquisition of data, analysis, interpretation of data, review/revision of the manuscript and provided final approval of the version to be published. They are the responsible for the overall content as guarantors. JMIT drafted and revised the manuscript and provided final approval of the version to be published. JP contributed to the conception and design of the study, interpretation of data, review/revision of the manuscript and provided final approval of the version to be published. BD and PGJT contributed to the interpretation of data, reviewed/revised the manuscript and provided final approval of the version to be published.
Funding This study received an Innovation Grant ($200 000) from the Covenant Health–Network of Excellence in Seniors Health and Wellness, Edmonton, Alberta.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval This study was deemed to be outside the mandate of the Health Research Ethics Board of the University of Alberta (Study ID # Pro00062100) and did not require ethics review.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement Data are available upon reasonable request. Data may be requested from Covenant Health.
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