Managing Posthospital Care Transitions for Older Adults: Challenges and Opportunities

In this issue of JAMA, Dhalla and colleagues1 report findings from a randomized trial comparing the effect of usual care vs a “virtual ward” model of posthospital care management for older adults on reducing the primary end point of 30-day hospital readmissions. The virtual ward focused on care coordination by telephone or e-mail contact as well as clinic or homevisits for severalweeks followinghospital discharge. WithMedicarehospital reimbursement increasingly tied to30day readmission rates, this study has potential clinical and financial implications. The study by Dhalla et al was well designed and aimed to test the model described, had successful randomization, targeteda representativegroupofolderpatientsathigh riskof readmission or death, and enrolled approximately 960 patients pergroup, sufficient todetect reducedhospitalization.The interventionwas intended to be scalable using existing hospital resources without substantial investment, specialized training, or role-specific expertise, which was cited as a potential weakness of some published models. The average intervention lasted 35 dayswithmultiple telephone or e-mail contacts (mean, 2.3 per patient), clinic visits (mean, 0.5), andhomevisits (mean, 2.8) by care coordinators (mean, 1.6), physicians (mean, 0.5), and pharmacists (mean, 0.75). One physician, in analternating role,was themedical authorityonthecare team inwhich the core clinical personnelwere care coordinators. It appears, based on the numbers of patients and teams, that a virtualwardhadamomentarycensusofabout30patients,modestly larger than a typical inpatient service. Despite the coordination of care and direct care provided by the interprofessionalteamforseveralweeksafterhospitaldischarge,therewere nostatisticallysignificantdifferencesbetweenthevirtualward group vs the usual care group in the primary outcome of hospital admission or deathwithin 30 days of discharge (21.2% in thevirtualwardgroup; 24.6%in theusual caregroup)or in the secondary outcomes of nursing home admission or emergency department visits at 30 days, or in any of these outcomes at 90 days, 6 months, or 1 year. How should these findings reported by Dhalla et al be interpreted in the context of the literature and clinical circumstanceofcomplexpatientsbeingdischargedfromhospitals?Previoussmallerrandomizedclinicaltrialshavereportedreductions in rehospitalization for specific groups of patients. In a study by Coleman et al2 that enrolled 370 per group in 2002 and had nursepractitionersaskeyagentsinmanagingpost-hospitalcare, 30-day readmissions in the intervention group (8.3%)were reduced by 30% relative to controls (11.9%)with hospital cost reductions of $488 per patient in 6months. In a 1992 study that enrolledabout180patientspergroupandinvolvedpatientswith control group hospital costs of $5507 (compared with control groupcostsinthestudybyColemanetal2adecadelaterat$2546) and a more intensive model, Naylor et al3 reported that comparedwithusualcare includinghomehealthcareservices inthe control group, a 4-week intervention involving experienced nurse practitioner transition teams resulted in 10% readmissionswithin 6weeks (17 of 177) comparedwith 25% (47 of 186) forcontrols,a62%relativereduction,andreducedhospitalcosts by $3093 per patient in 6 months. In that study,3 nurse practitionerteamssawpatients inthehospital,madeinitialhomevisitswithin48hours after discharge, andaveraged4.5homevisits,effectivelysubstitutingforsomehomehealthagencynursing visits provided to control patients. Other clinical models also have reported beneficial outcomes. In 2002, Shaughnessy et al4 described outcomes from structured quality improvement usingMedicare Part A home health care with 157 000 patients served by 54 intervention agencies in 27 states and 249 000 randomly selected control patients from those states. Risk-adjusted hospitalizationwas a required focus during 60-day care episodes by agencies. In 3years, interventionagenciesachievedapproximately25%improvement in hospitalization rates. These agencies described varied strategies, often involving interactions and communication with primary care physicians. De Jonge et al5 recently reported findings fromamatched case-control studyof a longitudinalmedically focusedhomebased primary care program with 721 patients who received about 15 home visits per year that demonstrated an associationbetween receiptof theprogramwith reducedhospital episodes (9%), emergency department visits (10%), and nursing homestays (27%), aswell as increaseduseofhomehealth care and hospice. Overall, Medicare costs were 17% lower over 2 years among patients who received the program than among those in thecontrol group.Similar findingsderive fromtheVeteransAffairsHome–basedPrimaryCare (HBPC) teammodel,6 operating in more than 130 centers. Comparing preenrollment with postenrollment periods for 9425 beneficiaries in 2006, hospitalizationswere 25% lower (11.7 vs 15.7 per 100patient-months) and total costs per patient-year were lower by $6148 ($45 980 vs $39 796) or 13.4%. These longitudinal inhome care team care models typically incorporate transitional care, concentrating efforts at times whenmedical conditions are less stable including posthospital transitions. The in-home primary care teammodel for complex Medicare paRelated article page 1305 Opinion