Abstract
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.