2054. Transitional Health Care from Hospital to Home
Andrea M Spehar, MPH, JD, VISN 8 Patient Safety Center, James A. Haley VA Hospital and University of South Florida and Floriday Safety Center, Inc. and Suncoast Center for Patient Safety, C Cherrie-Benton, VISN 8 Measurement Team, James A. Haley VA Hospital, D Scott,
Clinical Decision Support, University Community Hospital, JL Baker,
Clinical Decision Support, University Community Hospital, RR Campbell,
VISN 8 Patient Safety Center, James A. Haley VA Hospital, P Palacios,
VISN 8 Patient Safety Center, James A. Haley VA Hospital, B Bjornstad,
University Community Hospital, J Wolfson,
VISN 8 Patient Safety Center, James A. Haley VA Hospital, University of South Florida and Suncoast Center for Patient Safety and Stetson University of Law
Objectives: The goal of this study was to promote patient safety by examining the transition from hospital to home in vulnerable patients. The objectives were to (1) Identify patient-associated risk factors for readmissions and (2) Describe patient-perceived organizational processes that facilitated or impeded safe transition from hospital to home.
Methods: Retrospective and prospective approaches were used to examine two proximal hospitals: one VA and one non-profit community hospital. The retrospective sample included all discharges in 2001 with Heart Failure, Pneumonia, and CABG. Survival analyses identified factors associated with readmission. The prospective sample included patients readmitted within 30 days of discharge for these 3 DRGs. Patients were interviewed to determine issues and processes contributing to their readmission.
Results: Factors associated with readmissions varied by DRG. Numbers of secondary diagnoses, length of stay and CCS category were most consistently predictive of readmission. Age, gender, and race were not predictive. Patientsí perceptions of what might have prevented readmission included: longer hospital stay to ensure stabilization, enhanced patient education and involvement in decision-making, assuring medication/treatment effectiveness prior to discharge, home health nursing, more staff, and timeliness of follow-up appointments.
Conclusions: Some readmissions can be predicted and potentially reduced. Both patient factors and perceived organizational processes contribute to increased healthcare utilization.
Impact: These results aid in designing interventions to promote patient safety and address patient-perceived barriers and facilitators. The next phase is testing interventions to improve discharge planning and follow-up to reduce readmissions and healthcare costs, and improve patient satisfaction and quality of life.