A standardized post-discharge intervention reduced 30-day readmissions from 16.3% to 13.5% (P=0.07) and increased 14-day follow-ups to 70.0% (P=0.025) in a Medicare ACO.
Does a standardized, multidisciplinary post-discharge intervention reduce 30-day readmissions in a Medicare ACO population?
A standardized, multidisciplinary post-discharge intervention in a Medicare ACO population significantly increased 14-day follow-up appointments and showed a trend toward reduced 30-day readmissions.
Absolute Event Rate: 0% vs 0%
Preventable readmissions represent a significant opportunity to improve quality and reduce healthcare costs, with approximately 26% of Medicare medicine readmissions considered preventable. However, evidence on the effectiveness of post-discharge interventions at scale remains mixed, and implementing evidence-based practices consistently across large, diverse health systems is a challenge. To address these concerns, the Mass General Brigham Population Health Services Organization (MGB PHSO) developed and implemented a novel, multidisciplinary, system-wide post-discharge intervention aimed at reducing 30-day readmissions within its Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO). It was hypothesized that standardizing delivery through a high-fidelity workflow would reduce readmissions. A standardized, multidisciplinary program was created involving: (1) a coordinator conducting chart review and obtaining records; (2) a pharmacist performing medication reconciliation; and (3) a registered nurse completing a post-discharge assessment. A prospective cohort study was conducted comparing the outcomes of patients at pilot intervention sites with those of a propensity-matched control group. The intervention cohort showed a directional reduction in 30-day readmission rates compared to the matched controls (13.5% vs. 16.3%, P = 0.07) but no significant difference in 30-day emergency department presentations. The intervention group also had a significantly higher rate of 14-day follow-up appointments (70.0% vs. 65.3%, P = 0.025). These findings support the effectiveness of a centralized, standardized post-discharge strategy for reducing readmissions within an ACO setting. This study demonstrates that structured, system-level interventions can improve care transitions and outcomes in value-based care models.
Schiavoni et al. (Fri,) reported a other. A standardized post-discharge intervention reduced 30-day readmissions from 16.3% to 13.5% (P=0.07) and increased 14-day follow-ups to 70.0% (P=0.025) in a Medicare ACO.
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