Post-discharge intervention in vulnerable, chronically ill patients.

BACKGROUND: Studies suggest that the inpatient to outpatient transition of care is a vulnerable period for patients, and socioeconomically disadvantaged populations may be particularly susceptible.
OBJECTIVE: In this prospective cohort study, clustered by hospital, we sought to determine the feasibility and utility of a simple, post-discharge intervention in reducing hospital readmissions.
METHODS: Chronically ill Medicaid managed care members were consecutively identified from the discharge records of 10 area hospitals. For patients from the 7 intervention hospitals, trained medical assistants performed a brief telephone needs assessment, within 1 week of discharge, in which issues requiring near-term resolution were identified and addressed. Patients with more complicated care needs were identified according to a 4-domain care needs framework and enrolled in more intensive care management. Patients discharged from the 3 control hospitals received usual care. We used a generalized estimating equation model, which adjusts for clustering by hospital, to evaluate the primary outcome of hospital readmission within 60 days.
RESULTS: There were 97 intervention and 130 control patients. Intervention patients were slightly younger and had higher adjusted clinical group (ACG) scores. In unadjusted analysis, the intervention group had lower, but statistically similar, 60-day rehospitalization rates (23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24-1.00].
CONCLUSIONS: A simple post-discharge intervention and needs assessment may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse care needs.