Better transitions of care can decrease likelihood of hospital readmissions

Apr 3 2018

Hospital discharge after serious conditions are rife with potential for complication and confusion. Patients are often loaded with details that can be difficult to understand and process when dealing with the weight of surviving a heart attack. A new study of patients who experienced acute myocardial infarction shows that consistent discharge education and hand-off to non-hospital physicians can decrease the likelihood of premature return to the hospital after discharge by 48 percent.

"This study puts a number to the importance of having comprehensive protocols to follow up with our heart attack patients after they go home," said cardiologist David Whellan, MD, Associate Dean and Senior Associate Provost of Clinical Research at Jefferson (Philadelphia University + Thomas Jefferson University) and senior author on the study. The findings were published recently in the American Journal of Medical Quality.

The researchers evaluated Thomas Jefferson University Hospital's wrap-around discharge program. The program encompassed a number of interventions including a consultation with a pharmacist who reconciled the patient's existing medications with the new prescriptions and their potential side effects. A nursing team provided education on best practices for diet, reading materials on the disease, and implications for lifestyle changes and disease management. Finally, when necessary, a care team would assist the patient in finding a primary care physician, who could monitor the patient regularly, plan a follow-up visits, and do a patient check-in call seven days after discharge to answer questions and provide support as needed.

"Individually, many of these discharge interventions have not proven effective at decreasing readmission rates. The multi-faceted approach to education and follow up is really the key," said Dr. Whellan.

Dr. Whellan and colleagues looked at the outcomes and readmission rates of 304 patients who had received the multi-faceted discharge program at Jefferson. They compared those outcomes to 192 patients who were enrolled in the study in the eight months before the new discharge program was implemented at the hospital.

They saw a 48 percent reduction in the rate of readmissions in the group that received the comprehensive discharge program. Early readmission to the hospital was defined as returning within 30 days after initial discharge. While other studies have demonstrated similar reductions in readmissions for other chronic diseases, this is the first study to show an effect for patients who have suffered a heart attack.