Improving diabetic patient transition to home healthcare: leading risk factors for 30-day readmission.

OBJECTIVES: To identify risk factors of 30-day readmissions due to ambulatory care-sensitive conditions (ACSCs) for diabetic Medicare home healthcare beneficiaries in order to improve transition from hospital-based care to home healthcare. STUDY
DESIGN: We analyzed diabetic Medicare beneficiaries who received home healthcare within 14 days of hospital discharges in 2009. The unit of analysis is the home health episode for post acute care.
METHODS: The conceptual framework was guided by Andersen's Behavioral Model of Health Services. Data sources included: Medicare Beneficiary Summary File, Medicare Provider Analysis Review, Outcome Assessment Information Set, Home Health Agency Research Identifiable File, Hospital Readmissions Reduction Program Supplemental Data File, Provider of Services File, and Area Health Resources File. The dependent variable was time to first 30-day ACSC-related readmission. Proportional hazards regression was used for the statistical analyses.
RESULTS: The 30-day ACSC-related readmission rate was approximately 6% in our study sample, costing the Medicare program about $62 million. Predictors of readmissions due to ACSCs within 30 days of hospital discharge were: being aged 75 to 84 years, being an African American, requiring assistance in medication management, and having 1 or more of the following clinical conditions: congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, deficiency anemia, fluid and electrolyte diseases, depression and/or anxiety, and pressure or stasis ulcer. Patients with chronic obstructive pulmonary disease or renal failure had a 40% higher risk of 30-day ACSC-related readmissions than their counterparts.
CONCLUSIONS: Knowing the risk factors identified above, hospital providers can improve care planning and transition of care to the home healthcare providers.