Improving Care Transitions in Individuals Frequently Admitted to the Hospital

To the Editor: Individuals who are frequently admitted to the hospital have high levels of multimorbidity, polypharmacy, and functional impairment,1 and the sudden reduction in intensity of care in the posthospital period may contribute to high rates of hospital readmission.2-5 A multidisciplinary follow-up clinic for frequently admitted patients was piloted to address demonstrated gaps in transitional care.6 This report describes the patient perspective of care in this model. Participants were recruited from general medical wards of a metropolitan hospital in Brisbane, Australia, from June to December 2012. Consecutive inpatients aged 60 and older with at least one unplanned hospitalization in the previous 6 months were identified through the admissions database. Individuals were ineligible if they lived outside Brisbane, were discharged to residential care, were receiving palliative care, could not consent, or were receiving care from the heart failure service. Eligible individuals were invited to participate if their treating team agreed. The study received ethical approval. Participants were scheduled for clinic review within 2 weeks of discharge. The first visit included comprehensive assessment of social and medical services, symptoms, care goals, activities of daily living, malnutrition, and depression by a registered nurse. A clinical pharmacist undertook review of medication use after discharge, current medication understanding, and adherence. The physician then reviewed medical conditions and treatments and recommended a treatment plan, including referrals as needed. A physiotherapist or exercise physiologist assessed each participant and prescribed an individualized exercise program in a supervised weekly group exercise class or at home. A comprehensive summary with recommendations was sent to the general practitioner within 5 days, and at least two further reviews were scheduled over 12 weeks to assess progress and adjust management, with telephone support as required. Participant perceptions were measured using the 15-item Care Transitions Measure (CTM-15), a reliable measure of quality of transitional care.7, 8 The CTM-15 was administered at the initial visit (reflecting hospital discharge) and at 12 weeks (reflecting clinic experience). Items were scored from 1 (strongly disagree) to 4 (strongly agree), and the CTM-15 score was calculated by averaging and linear transformation as originally described.8 Baseline and 12-week CTM-15 scores were compared using paired t-tests; mean nontransformed scores for each item were compared using paired t-tests. Of 199 patients screened, 52 were eligible (73 residential aged care, 46 heart failure service, 11 palliative, 16 other exclusions). The hospital team chose usual care for 24 patients; nine declined, and 19 consented, of whom 17 attended the service. Mean age was 77 (range 61–95), 10 were male, and 11 lived alone. Admissions were for acute infection (n = 7), exacerbation of chronic disease (n = 7), falls (n = 2), and pain (n = 1). All participants reported seeing their general practitioner at least once a month. Participants had a median of 20 (interquartile range (IQR) 10–46) previous admissions and were taking a median 15 of medications (IQR 9–19). Two participants did not complete the final CTM-15 questionnaire, leaving 15 participants with matched data. Mean CTM-15 score was 65.0 ± 8.7 at the first visit and 73.6 ± 12.9 at 12 weeks (P = .03), and 10 (66%) had a 5-point improvement. Individual item scores are shown in Table 1. At hospital discharge, half of the respondents disagreed that their goals and preferences were considered. Most agreed that they had knowledge, understanding, and confidence to manage their health, but scores were poorer for detailed understanding (what made their conditions better and worse, recognizing signs and symptoms, understanding medication side effects). Only 12% had a clear written list of tests and appointments or a written care plan at hospital discharge. Most gaps improved significantly after 12 weeks (Table 1). This sample of individuals frequently admitted to the hospital reported gaps in transitional care, with an overall mean CTM-15 score of 65 at discharge. This is similar to older adults with chronic medical conditions in the United States but lower than individuals with cancer in Israel.8, 9 Scores were lowest for individualized patient education (symptoms and signs, exacerbating factors, medication side effects) and written information, as demonstrated in previous studies 7-9 and consistent with a recent chart-based review of frequent attenders.6 The significant improvement in CTM-15 score is encouraging and likely to be clinically important; validation studies demonstrated that a 5 point difference discriminated between readmitted and non-readmitted patients.7, 8 Improvements in items measuring individualized care and patient education reflect the aims of the clinic. Although this feasibility pilot is limited by small sample size and lack of a concurrent control group, this positive patient experience will inform a larger controlled trial to assess clinical outcomes of the new model. We are grateful to Mrs. Jessica Suna for assistance with patient screening. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. The study was supported by funding from the Royal Australasian College of Physicians and the Royal Brisbane and Women's Hospital Research Foundation.