Evaluating the effectiveness of a transitional care program in an acute care organization
Creators: name: Jimenez, Jeanette
Publisher: name: No Publisher Supplied
Year: 2022

description: Purpose of Project: The Centers for Medicare &amp; Medicaid Services (CMS) penalizes hospitals for disproportionately high 30-day readmission rates of patients. Hospital recidivism has been associated with non-compliance with prescribed medication and attendance of follow-up visits. Numerous transitional care programs have been implemented to facilitate the discharge process from hospital to home settings to decrease the risk of readmission. However, transitional programs do not consistently demonstrate success in reducing readmission rates. This project aimed to evaluate the efficacy of a transitional care program at a large urban hospital located in northern New Jersey over a six-year time period. Methodology: A longitudinal non-experimental design was utilized to compare prescription adherence, follow-up visit adherence, and readmission rates of patients diagnosed with AMI, COPD, or pneumonia between January 2015 to July 2021. Compliance data were extracted from a retrospective chart review and readmission data were compiled and provided by the facility. A chi-square analysis measured and compared frequency trends for the three outcomes over six-years. Staff fidelity to communicate with patients two days, seven days, and twenty-one days post discharge was also measured and correlated to the three outcomes for each year. Results: A total of 300 medical charts of Medicare patients treated between January 2015 and July 2021 were retrospectively reviewed. The sample was 61.5% female and 38.7% male and were diagnosed with AMI (29.6%), COPD (38.5%), and pneumonia (31.8%). The proportion of patients who adhered to a prescribed medication protocol increased from 32.8% in 2015 to 73.3% in 2021. A chi-square test estimated that the 40.5% increase in medication adherence over six years was highly significant (X2=36.0, p=.001). It was also determined that adherence to follow-up visits increased from 26.6% in 2015 to 33.3% in 2021.The 7.3% increase was also statically significant (X2=18.8, p=.005). Readmission data provided by the facility reported an average annual readmission rate of 17.38% in 2015 and 9.22% in 2021. However, reductions in the frequencies of readmissions did not reach statistical significance (X2=42.0, p=.227). The relationship between communicating with patients two days post discharge and adherence to medications was strong (R2=.850, p=.015). The relationships between communication with patients seven days after discharge and follow-up visit adherence (R2=.810, p=.027), as well as twenty one day communication and adherence to follow-up care (R2=.869, p=.011) were also strong. Implications for Practice: This project provided evidence that the transitional care program at this hospital facility was able to significantly improve adherence to medication protocols and attendance to follow-up care. Findings suggests that the transition program may be highly effective with improving certain patient behaviors, although significant reductions in readmission rates were not established. Readmission rates may have been further complicated by the COVID-19 pandemic which has greatly impacted healthcare delivery between 2020 and 2021. Outcomes should be assessed by considering staff fidelity to TCC requirements and additional factors without interference of the COVID-19 pandemic. The project findings are beneficial in improving future transitional care programs and patient self-management of care, and decreasing CMS penalties by reducing hospital recidivism.