The successes and challenges of hospital to home transitions

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al. report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children. As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions. Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities. The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient’s transition home after discharge. In adult studies, this “bridging strategy” (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review and adult reviews focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a “transition coach” to aid the patient in medication self-management, creation of a patient-centered record, scheduling follow-up appointments, and understanding signs and symptoms of a worsening condition. In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group. One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14-day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program. This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program. Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease-specific interventions to other populations, and (4) how to evaluate the cost and assess the cost–benefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al., in which the intervention group received a combination of an enhanced discharge education session, disease-specific nurse evaluation, an animated education booklet, and postdischarge telephone follow-up, whereas the control group received a shorter discharge education session, a disease-specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone followup. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al. was unable to detect a difference in readmissions or ED revisits. *Address for correspondence and reprint requests: Samir S. Shah, MD, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., MLC 9016, Cincinnati, OH 45229-3039; Telephone: 513–636-0409; E-mail: samir.shah@cchmc.org