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Open Access Research article

Integrated postdischarge transitional care in a hospitalist system to improve discharge outcome: an experimental study

Chin-Chung Shu12, Nin-Chieh Hsu12, Yu-Feng Lin12, Jann-Yuan Wang2, Jou-Wei Lin3 and Wen-Je Ko14*

Author Affiliations

1 Department of Traumatology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan

2 Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei city 100, Taiwan

3 Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, No. 579, Yun-Lin Road, Douliou city, Yun-Lin county 640, Taiwan

4 Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei city 100, Taiwan

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BMC Medicine 2011, 9:96  doi:10.1186/1741-7015-9-96

Published: 17 August 2011

Abstract

Background

The postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. In this study, we aimed to investigate the impact of a quality improvement program, integrated postdischarge transitional care (PDTC), in Taiwan's hospitalist system.

Methods

From December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan and later discharged alive to home care were included. Efforts to improve the quality of interventions in the PDTC program, including a disease-specific care plan, telephone monitoring, hotline counseling and referral to a hospitalist-run clinic, were implemented in the latter four months in the intervention group, while the control group was recruited during the first two months of the study period. The primary end point was unplanned readmission or death within 30 days after discharge.

Results

There were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics at the time of admission and at discharge. In the intervention group, 18 patients with worsening disease-specific indicators recorded during telephone monitoring and 21 patients with new or worsening symptoms recorded during hotline counseling had higher rates of unplanned readmission than those without worsening disease-specific indicators (P = 0.031) and worsening symptoms (P = 0.019), respectively. Patients who received PDTC had lower rates of readmission and death than the control group within 30 days after discharge (15% vs. 25%; P = 0.021). Nonuse of a hospitalist-run clinic and presence of underlying malignancy were other independent risk factors for readmission and death within 30 days after discharge.

Conclusion

Integrated PDTC using disease-specific care, telephone monitoring, hotline counseling and a hospitalist-run clinic can reduce rates of postdischarge readmission and death.