Transitional Care Can Reduce Hospital Readmissions
Transitional Care Can Reduce Hospital Readmissions
Patient factors that pose a risk for readmission include comorbid medical conditions, previous acutecare hospitalizations and ED visits, older age, lack of social support, poor access to healthcare services, substance abuse, poor health literacy, and functional limitations. Patients who lack strong family support also are at risk for readmission, and family members commonly have inadequate input into transitional care planning because they're not included in discussions. Too often, only the patient receives self-management education, even though family caregivers provide the actual care. Also, weekend discharges can put patients at risk for readmission due to lack of available support services, such as pharmacies and durable medical equipment companies, during weekend hours.
Transitional care programs are resource-intensive and are most likely to be effective when they target individuals at highest readmission risk. In one study (Kansagara, et al), researchers conducted a systematic review of currently available tools used to predict a patient's risk for readmission and evaluated 13 instruments with potential use in deciding which patients would benefit most from transitional care services. They found that although risk tools overall had poor predictive ability, high- and low-risk scores correlated with readmission rates in a clinically significant manner.
Another researcher (Wodchis) criticized the Kansagara study for not considering the intent of the tools in its review. Wodchis studied tools designed to select patients for transitional care interventions and assessed their comparative abilities to predict acute- and long-term care use. This study included five tools. The author found that patients identified by each tool differed significantly, because each tool was designed to identify different risk factors. Wodchis found the tools have predictive value but predicted differing outcomes. The Probability of Repeated Admission (Pra) tool and the LACE index were the best predictors of 30-day acute-care readmissions and ED visits. But because these tools use unmodifiable risk factors to assess risk, they provide little direction for targeted transitional care activities.
A three-study meta-analysis involving five cohorts of subjects (n = 8,843) evaluated the validity of the Pra tool. The researchers found Pra to be a good predictor of hospital admission in subjects who achieved high scores on the assessment. Unfortunately, this tool has poor sensitivity, so many patients with low scores not identified as high risk for readmission may be categorized inaccurately and thus fail to receive the transitional care services they need. The Pra tool is easy and quick to administer and considers age, gender, presence of diabetes and cardiac disease, hospital and primary care use, self-rated health, and caregiver availability to assess risk for hospital admission. Scores range from 0 to 1; a score of 0.5 indicates a 50% risk for two or more hospitalizations within the next 4 years or one or more admissions in the following year.
The LACE index is a valid algorithm useful in identifying patients likely to benefit from post-discharge care. LACE scores range from 0 to 19; patients scoring 10 or above are at high risk for readmission or death and are likely to benefit from post-discharge services. Like the Pra tool with its cutpoint of 10, the LACE tool accurately identifies high-risk patients but misses a significant number with low scores who will be readmitted. Administered during hospitalization, the LACE tool considers:
Patients with the essential skills and confidence to engage actively in their own healthcare discharge planning are far less likely to be readmitted to the hospital and less likely to overuse the ED. The term patient activation describes six key components of engagement—selfmanagement of symptoms and health problems, engagement in health-promoting activities to optimize function, involvement in treatment decisions, collaboration with healthcare professionals, active identification of high-quality healthcare organizations and providers, and ability to navigate the healthcare system.
A developmental process, patient activation has four identifiable stages.
Patients in stages 3 and 4 have lower levels of 30-day readmission rates than those at lower activation levels.
The Patient Activation Measure (PAM), a 13-item survey with good validity and reliability across multiple demographic groups, can be used to determine a patient's activation level before hospital discharge. It also can be used to identify readmission risk and guide specific tailored interventions based on the patient's activation level.
In 2013, URAC (formerly called the Utilization Review Accreditation Commission) proposed using PAM to identify at-risk patients, appropriately direct interventions and resources to high-risk patients, and enhance patient activation. Unfortunately, PAM is copyrighted and its use requires purchase of a licensing agreement. Costs vary with organization size, and licenses must be purchased every 12 months. Costs vary from $2,000 for use with up to 1,000 participants to $7,500+ for organizations planning to use the tool with more than 2,000 patients in 12 months.
Targeted Care Transition: Readmission Risk Factors and Risk Assessment
Patient factors that pose a risk for readmission include comorbid medical conditions, previous acutecare hospitalizations and ED visits, older age, lack of social support, poor access to healthcare services, substance abuse, poor health literacy, and functional limitations. Patients who lack strong family support also are at risk for readmission, and family members commonly have inadequate input into transitional care planning because they're not included in discussions. Too often, only the patient receives self-management education, even though family caregivers provide the actual care. Also, weekend discharges can put patients at risk for readmission due to lack of available support services, such as pharmacies and durable medical equipment companies, during weekend hours.
Transitional care programs are resource-intensive and are most likely to be effective when they target individuals at highest readmission risk. In one study (Kansagara, et al), researchers conducted a systematic review of currently available tools used to predict a patient's risk for readmission and evaluated 13 instruments with potential use in deciding which patients would benefit most from transitional care services. They found that although risk tools overall had poor predictive ability, high- and low-risk scores correlated with readmission rates in a clinically significant manner.
Another researcher (Wodchis) criticized the Kansagara study for not considering the intent of the tools in its review. Wodchis studied tools designed to select patients for transitional care interventions and assessed their comparative abilities to predict acute- and long-term care use. This study included five tools. The author found that patients identified by each tool differed significantly, because each tool was designed to identify different risk factors. Wodchis found the tools have predictive value but predicted differing outcomes. The Probability of Repeated Admission (Pra) tool and the LACE index were the best predictors of 30-day acute-care readmissions and ED visits. But because these tools use unmodifiable risk factors to assess risk, they provide little direction for targeted transitional care activities.
Pra Tool and LACE Index
A three-study meta-analysis involving five cohorts of subjects (n = 8,843) evaluated the validity of the Pra tool. The researchers found Pra to be a good predictor of hospital admission in subjects who achieved high scores on the assessment. Unfortunately, this tool has poor sensitivity, so many patients with low scores not identified as high risk for readmission may be categorized inaccurately and thus fail to receive the transitional care services they need. The Pra tool is easy and quick to administer and considers age, gender, presence of diabetes and cardiac disease, hospital and primary care use, self-rated health, and caregiver availability to assess risk for hospital admission. Scores range from 0 to 1; a score of 0.5 indicates a 50% risk for two or more hospitalizations within the next 4 years or one or more admissions in the following year.
The LACE index is a valid algorithm useful in identifying patients likely to benefit from post-discharge care. LACE scores range from 0 to 19; patients scoring 10 or above are at high risk for readmission or death and are likely to benefit from post-discharge services. Like the Pra tool with its cutpoint of 10, the LACE tool accurately identifies high-risk patients but misses a significant number with low scores who will be readmitted. Administered during hospitalization, the LACE tool considers:
Length of the hospital stay
Acuity on admission to the hospital
Comorbid conditions
Emergency visits in the 6 months before hospitalization.
Patient Activation
Patients with the essential skills and confidence to engage actively in their own healthcare discharge planning are far less likely to be readmitted to the hospital and less likely to overuse the ED. The term patient activation describes six key components of engagement—selfmanagement of symptoms and health problems, engagement in health-promoting activities to optimize function, involvement in treatment decisions, collaboration with healthcare professionals, active identification of high-quality healthcare organizations and providers, and ability to navigate the healthcare system.
A developmental process, patient activation has four identifiable stages.
Stage 1: Patients don't realize the importance of taking an active role in their own health.
Stage 2: They lack the knowledge and confidence to participate effectively in their own health care.
Stage 3: They begin to take an active role in their care but may lack confidence to assert themselves adequately in care planning.
Stage 4: They generally play an active, effective role in maintaining their own health but may struggle during times of excessive stress or illness.
Patients in stages 3 and 4 have lower levels of 30-day readmission rates than those at lower activation levels.
PAM Measure
The Patient Activation Measure (PAM), a 13-item survey with good validity and reliability across multiple demographic groups, can be used to determine a patient's activation level before hospital discharge. It also can be used to identify readmission risk and guide specific tailored interventions based on the patient's activation level.
In 2013, URAC (formerly called the Utilization Review Accreditation Commission) proposed using PAM to identify at-risk patients, appropriately direct interventions and resources to high-risk patients, and enhance patient activation. Unfortunately, PAM is copyrighted and its use requires purchase of a licensing agreement. Costs vary with organization size, and licenses must be purchased every 12 months. Costs vary from $2,000 for use with up to 1,000 participants to $7,500+ for organizations planning to use the tool with more than 2,000 patients in 12 months.
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