Identifying keys to success in reducing readmissions using the ideal transitions in care framework

Abstract

Background: Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions.

Methods: Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework.

Results: 66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0).

Conclusions: Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.

Figure 1

Selection of studies. Legend: Selection of studies after application of inclusion and exclusion criteria is shown.

Figure 2

Number of ITC domains addressed per intervention. Legend: The distribution of the number of domains of the ITC framework included in each intervention is shown.

Figure 3

ITC domains addressed across interventions. Legend: The percent of interventions that included a particular domain of the ITC framework is shown. MM = Monitoring and Managing Symptoms After Discharge; EP = Patient Education to Promote Self-Management; CCA = Coordinating Care Among Team Members; DP = Discharge Planning, FO = Outpatient Follow-Up; EH = Enlisting Help of Social and Community Supports; MS = Medication Safety; AT = Accuracy, Timeliness, Clarity, and Organization of Information; CCI = Complete Communication of Information; AP = Advance Care Planning.