Key result
The Care Coordination Cocoon for multiply readmitted patients decreased readmissions, with 48-hour calls independently associated with reduced readmission odds (OR 0.21; 95% CI 0.09-0.50).
Why the study?
Current evidence suggests a lack of universal benefit from transition of care processes, prompting an evaluation of factors associated with hospital readmissions and the construction of a model to reduce 30-day readmissions.
Does targeted care coordination (Care Coordination Cocoon) reduce 30-day hospital readmissions in patients with a history of multiple readmissions?
Observational (n=264)
Does targeted care coordination (Care Coordination Cocoon) reduce 30-day hospital readmissions in patients with a history of multiple readmissions?
Odds Ratio: 0.21 (95% CI 0.09–0.5)
Targeted care coordination with weekly contact for patients with multiple prior readmissions is associated with significantly reduced 30-day readmission rates.
May inform TOC patient selection; leaves open whether model-based interventions reduce 30-day readmissions.
BACKGROUND: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions. METHODS: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission. RESULTS: Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis. CONCLUSIONS: Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.
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Wellman et al. (2023) conducted an observational in Multiple hospital readmissions (n=264). Care Coordination Cocoon (CCC) vs. Standard transition of care (pre-intervention) was evaluated on Hospital readmission (OR 0.21, 95% CI 0.09-0.50). The Care Coordination Cocoon for multiply readmitted patients decreased readmissions, with 48-hour calls independently associated with reduced readmission odds (OR 0.21; 95% CI 0.09-0.50).
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