The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities.

Abstract

Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.