Hospital Readmissions: Reducing Risk

This assignment delves into the crucial issue of hospital readmissions, analyzing their causes and potential solutions. It presents a collection of research articles and case studies examining various risk factors, including patient demographics, medical conditions, and post-discharge care. The focus lies on understanding effective interventions to mitigate readmission rates and enhance patient outcomes.

Need special attention on – RFP
QUESTION:
1. What is the state of our knowledge of risk factors (individual, organizational, or system) for
readmission?
2. Given the limitations, why is this design appropriate compared to other potential designs?
3. How will these participants be sampled or represented in the study design?
Quantitative Research

Table of Contents
Executive summary……………………………………………………….3
Introduction……………………………………………………………….4
Objecives………………………………………………………………….5
Methodology……………………………………………………………....5
Design and setting………………………………………………………....5
Patients…………………………………………………………………….5
Inclusion criteria…………………………………………………..6
Exclusion criteria………………………………………………….6
Strengths and limitations…………………………………………………..6
Strengths…………………………………………………………...6
Limitations…………………………………………………………6
Rationale for intervention…………………………………………………..6
Data collection……………………………………………………………...7
Dependent variables………………………………………………………...7
Independent variables……………………………………………………….7
Resources necessary for evaluation of hospital readmissions………………8
Implementation strategy…………………………………………………….8
Outcomes……………………………………………………………………8
Data analysis………………………………………………………………...9
References…………………………………………………………………….14

Executive summary:
Repetitive hospital readmission among psychiatry patients reflects quality of nursing and
medical care received by these patients. Hospital readmissions can be effectively controlled
by implementing pre and post discharge treatment. Not only medical treatment but also
patient related factors are responsible for hospital readmissions. It is evident that rate of
hospital readmissions in Ontario have been high. Hence, it is necessary to reduce rate of
hospital readmissions. In this proposal, parameters required to reduce hospital readmissions
will be evaluated. Identifying these parameters will be helpful in reducing risk of hospital
readmissions. In this evaluation programme pre-test and post-test study design will be
implemented. In the pre-test baseline characteristics of the patients will be collected and in
post-test impact of the evaluation programme will be evaluated at days 30, 60 and 90.
Inclusion and exclusion criteria will be set for the patients to decide eligibility for enrolment
in the programme. Patients will be randomised in control and intervention arm based on the
baseline characteristics. Psychiatric counselling will be provided to intervention arm patients
only. Environmental factors as the internal validity and population external validity will be
strength of this programme. Maturation and carryover effect as internal validity and
ecological external validity will be limitations of this evaluation programme. Participants will
be selected from the 15 hospitals. Data from the hospital health information systems and self-
reporting by patients will be used for the evaluation of effectiveness of the hospital
readmission reduction programme. Descriptive statistics will be used for the analysis of the
data. Data for readmissions within 30, 60 and 90 days will be analysed separately.
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Introduction:
Repeated hospitalisation is mainly dependent on the type and severity of psychiatric disorder.
Repeated hospitalisation also reflects environmental and social aspects. Along with this, it
also reflects deficiencies in pre and post discharge treatment. Readmissions can affect both
patients and their families and hospitals1. Both patient families and hospital can experience
psychological strain and financial burden. Hospital readmissions can be prevented by
providing holistic care during the hospital stay, planned discharge and transition and adequate
follow-up. Reduction in the hospital readmissions can be helpful in improving acceptance of
the psychiatric patient in the society and improving confidence of the patient2.
Usually, hospital readmissions within 30 days is considered as poor clinical outcome in case
of psychiatric disorders. This poor outcome might be due to inadequate community-based
care after discharge, self-care and difficulties in adherence to the psychiatric medication. It
has been estimated that approximately 9 % patients with principal mood disorders were
readmitted and 12 % patients with any diagnosis of mood disorders were readmitted. It has
been estimated that approximately 16 % patients with principal schizophrenia were
readmitted and 19 % patients with any diagnosis of schizophrenia were readmitted. Adequate
care at home can be used as a good indicator for reduced readmission for psychiatric
disorders. However, it has been estimated that only 1 – 6 % patients with mood disorders and
schizophrenia receive proper care at home3. Initial cost for the management of psychiatric
disorders is lower as compared to the other conditions. However, readmission cost for
psychiatric disorders is more as compared to other disorders. As compared to other
conditions, patients with psychiatric conditions like mood and schizophrenia are with more
discharge disposition of home-care or self-care. 89 % patients with mood disorders and 78 %
patients with schizophrenia are with discharge disposition of home-care or self-care. 62 %
patients with other than psychiatric conditions are with discharge disposition of home-care or
self-care4.
Mood disorder and schizophrenia are the major causes of hospital readmissions along with
other causes like alcohol related disorders and substance related disorders. Male patients (14
%) are more prone to readmissions as compared to the female patients (12 %). 12.5 %, 14.5
% and 12.6 % patients were readmitted between age group 18-44, 45-64 and above 65
respectively. Patient level predictors of hospital readmissions can be confounding however
system level predictors like capacity, structure or treatment of organisation can be definite
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predictors of hospital readmissions. Patient level predictors like length of stay and patient
receiving aftercare are the confounding predictors of hospital readmissions.
Objectives:
To determine whether counselling delivered telephonically by mental health professional
instantly followed by discharge is efficient in reducing risks of hospital readmissions
according to interRAI MH.
To evaluate whether this strategy is helpful in reducing clinical psychological symptoms
significantly.
Methodology:
Design and setting:
A matched cross over study will be implemented for the reduction of hospital readmission for
psychiatric patients. This pre-post-test design study will be conducted between January 1,
2016 to October 31, 2016. Pre and post test, can be helpful in evaluating impact of
intervention because parameters prior to and after completion of intervention can be
compared in the same population. Pre and post intervention can be useful in measuring value
addition to the samples in the programme. This programme will be implemented in the 15
hospitals of the Ontario Hospital Association and Health Quality Ontario. Evaluation of the
implemented programme will be carried out between January 2016 to October 2016. This
study will be sub-divided in three-time periods. The pre-test period will be ranged from
January 2016 to March 2016, the intervention will be implemented between April 2016 to
June 2016 and post-test period will be ranged from June 2016 to October 2016. In this study,
2000 patients will be enrolled from the different Ontario Hospitals based on the mentioned
exclusion and inclusion criteria. These number of patients will be enrolled because it will
give power for statistical significance. Out of these, 1000 patients will be randomised to the
control arm. For control arm patients, normal discharge will be provided followed by normal
care. Remaining 1000 patients will be randomised to intervention arm and to these patients
normal discharge will be provided followed by telephone based counselling. Telephone based
counselling will be provided for the duration of 4 weeks. Blocked randomisation schedule
and two sets of sealed envelopes will be prepared for the randomisation. One set of envelop
will be labelled as control arm and another as intervention arm. Patients will be allowed to
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open the folders and they will be allocated to control and intervention arm based on their
envelops5.
Patients:
Inclusion criteria:
Patients enrolled in the study need to meet following criteria : a) all the patients should be
above age 18 years, b) should be admitted to the hospital for more than 4 hours, c) patients
should be discharged home, d) should have working telephone, e) should speak English, f)
devoid of medical record of cognitive impairment, g) screen positive for mood disorder and
schizophrenia and g) should have life expectancy of more than 90 days.
Exclusion criteria: a) patient should not be planned for inpatient rehabilitation, nursing home
or other healthcare facilities after discharge, b) suicidal tendency, c) alcohol and/or drug
dependence, and d) in police custody6.
Strengths and limitations:
Strengths:
Strengths: Environmental factors can influence internal validity of study design. However, in
this study, control group will be incorporated along with intervention group. Hence, it would
be helpful in neutralising environmental effect. Population external validity will be the
strength of this study because results of this study can not be generalised to patients without
intervention for psychiatric disorders.
Limitations: Maturation and carryover effect can affect internal validity in this study design.
Maturation can occur due to change in participants for pre-test to post-test. Carryover effect
occur due to influence of pre-test on the outcome of post-test. Ecological external validity can
be limitation in this study design because home environment can be different from the
hospital environment7, 8.
Though this study is associated with limitations, this study is more useful as compared to
other designs because it gives data about the real world study. Results of this study can be
used as evidence for the future studies. Control and intervention groups can be compared in
this study. Statistical power can be obtained in this study.
Rationale for evaluation programme:
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Data related to hospital readmissions will be collected for the duration of 6 months.
Evaluation of the programme will be helpful for the amendment and improvement of the
evaluation programme. Intervention will be provided to the patients for 4 weeks with twice a
week frequency.. For the reduction of the hospital readmissions, counselling should be
provided to the patients and family members. Hence, telephone-based counselling will be
provided to reduce risk of hospital readmissions. Risks of readmissions include interRAI
variables like prior hospitalizations, greater severity in several clinical conditions such as
psychosis, presence of a secondary substance use diagnosis, and being unemployed.
Counselling will comprise of aspects like improve patient engagement and adherence to the
intervention9.
Data collection:
There are different sources of data like existing data and new data. Existing data comprising
of information given by OHA/HQO and HIS. It includes health service use, diagnoses, living
arrangements and employment, mental health symptoms, substance use, and functioning, and
rehospitalization CAP. New data will be collected by trained research nurse. Equivalent data
will be collected pre-intervention and post-intervention. After the completion of four weeks
counselling sessions to the patients, telephone survey will be conducted to assess hospital
readmission status and treatment utilization for psychiatric condition. Data will comprise of
baseline data of patients, duration of index hospitals stay, diagnosis during hospital
admission, symptoms and comorbidities. Information related to living conditions,
employment status, abusive substance use and functioning will also be collected. Data related
to hospital admissions in the six months prior to index admission will also be collected.
Health information system (HIS) will be helpful in gathering personalised information about
the patient in terms of discharge summaries, prescribed medicines, results of diagnostic
laboratory test, clinical and imaging biomarkers. HIS will be helpful in improving patient
safety, improving quality of intervention and avoiding unnecessary readmissions10.
Dependent variables:
Period between discharge and readmission will be considered as the dependent variable.
Collected data like baseline data of patients, duration of index hospitals stay, diagnosis during
hospital admission and comorbidities will be corelated with readmissions within timeline of
30, 60 and 90 days. Readmissions within 30, 60 and 90 days will be compared with each
other. It will be helpful in corelating severity of disease, type of disease, prescribed medicines
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and age of the patient with each of the readmission timeline. This programme will also assess
the measures for readmission of the psychiatric patients. Readmission data will be helpful in
answering the proposal question11,12.
Independent variables :
Demographic factors, medical treatment and healthcare utilization are the risk factors mainly
responsible for the readmission of psychiatric patients. Demographic factors include sex, age,
income and educational level. Age will be important independent variable because with the
increase in the age there will be more severity of the psychiatric disease. Comparison among
male and female will be analysed for hospital readmissions because from the literature it is
evident that male is more prone to hospital readmissions as compared to female. This study
will be helpful in further validating more susceptibility of male towards hospital
readmissions. Unemployment and illiteracy are the prominent reasons responsible for the
hospital readmissions in the psychiatric patients. Hence, income and education level will be
assessed as independent variable in this study. Accurate administration of the medicines for
psychiatric conditions and adequate utilization of healthcare facilities will be helpful in
reducing hospital readmissions11,12.
Evaluation strategy:
This proposal will incorporate engagement of the skilled healthcare professionals for the
evaluation of hospital readmissions. It will also include training for medical professionals for
evaluation of hospital readmissions. Healthcare professional will be trained for compilation,
analysis and interpretation of the results. Fixed tabular formats will be prepared for
compilation of the results. Statistical Package for the Social Sciences (SPSS) will be used for
the analysis the data. Trained statistician will be recruited for the statistical evaluation of the
data13.
Several activities will be planned for the effective evaluation of the implemented programme
for hospital readmission reduction programme. Medical and nursing staff will be trained for
the discharge activities and readmission evalaution by programme coordinator. On monthly
basis meetings will be implemented for the evaluation of implementation of the programme.
Stakeholders of this meeting will comprise of project coordinator, the staff nurses and
medical specialist, senior level registered nurse and residents. Different interRAI variables
like prior hospitalizations, greater severity in several clinical conditions such as psychosis,
presence of a secondary substance use diagnosis, and being unemployed will be enquired by
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the stakeholders of the evaluation programme. Comparison will be done for these interRAI
indicators before and after the implementation of the programme. Telephonic call will be
arranged for recruited patients twice a week for the duration of four weeks14.
Outcomes:
Primary endpoint of this programme will be hospital readmission within 30 days followed by
within 60 days and 90 days. Hospital readmissions will be measured in two different ways :
1) data retrieval from the hospital records and 2) self-reporting by the patients. Secondary
outcomes will include length of hospital stay after readmission, time to hospital readmission,
frequency and duration of readmission, total number of general practitioner or emergency
department visits and patient satisfaction in discharge process. Separate medical records will
be maintained for the patients, those can’t be contacted within four weeks of counselling
session15,16.
Data analysis using descriptive and multivariate statistical tools:
In the initial phase, balance of patient characteristics will be measured because it should be
equally distributed among control and intervention group due to randomisation. Descriptive
statistics will be used for the analysis of patient psychiatric characteristics. Differences
between the pre and post test will be evaluated by applying chi-square or Student t-tests.
Statistical analysis will be carried out separately for hospital readmissions within 30, 90 and
180 days. Percentage of hospital readmissions in the individual hospitals will be calculated.
Readmission rate will be compared with varied factors like patient related factors
(demographic status, educational status, living conditions and employment status), disease
related factors (severity of the disease, types of symptoms) and hospital related factors
(utilization of healthcare facilities). Biasness due to different set up of hospitals will be
reduced by categorising hospitals in the different groups. External validity will be monitored
by controlling hospital characteristics. These hospital characteristics include region, hospital
proximity and patient discharge volume. Subgroup analysis will also be performed. Patients
admitted to the hospital prior to the index hospitalisation will be at higher risk of readmission.
Hence, subgroup analysis is required in these patients. Age, sex, discharge diagnosis and total
number of readmissions in the last six months prior to index admission will be used as
covariates or confounding factors2, 17, 18. Hospital readmissions evaluation programme can be
affected by multiple factors like evaluation design, variables affecting design and outcome of
the evaluation programme, alternatives to hospital readmissions, changes in readmissions
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with respect to different patient and impact of different stakeholders in the evaluation
programme. Hence, multivariate analysis will be used in this evaluation programme because
it can give statistical outcome considering multiple factors. Confidence interval will be
computed from the observed data. For each parameter confidence interval will be computed
for prior and after hospital readmission. 5 % confidence interval will be considered as
statistically significant. Comparison will be made prior and hospital admission.
Table 1 : Evaluation team involved in programme will be as follows19 :
Team Members Role and task
Principal investigator Main task in the evaluation process is to
oversee evaluation implementation,
submitting reports and having ultimate
responsibility of the program.
Project coordinating person
Trained statistician
Internal evaluator
The main role will be overseeing
administrative and fiscal functions
Statistics task.
Internal evaluator will be responsible in
conducting surveys, gathering information
and analyzing data
External evaluator This will be responsible in designing and
guiding the evaluation process of the
program process. He/she will review
internal findings, engaging in external
assessments and offers reports to funder.
Table 2 : Baseline characteristics of study population20,21
Characteristics Pre-test Post-test Cl value
Patients (n) 1000 1000
Age, mean (SD),
years
Male %
Female %
Employment status
Employed
Un-employed
Educational status
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Schooling
College
Graduation
Readmission to the
hospital within 6
months of index
admissions
Length of index
hospital stay
Table 3 : Evaluation matrix
Planning Implementation Outcome Data
source
Data collection
tool
Analysis
What is the
prevalence of
the problem?
Does the
patients status
affected by
mood status,
history of
hospitalization,
substance
abuse, living
status,
employment
status ?
How many
individuals are
participating?
What are the
changes in
performance?
How many/what
resources are
used during
implementation?
How many
participants are
attending
telephonic
counselling
sessions ?
Is there a
change in
quality of
life? Is there
a change in
health
measures? Is
there a
difference
between
before and
after?
Has the
patient
displayed
potential risk
as per CAP
HIS Survey
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guideline?
What is the
readmission
frequency of
the patient,
30,90 or 180
?
What is the
first
readmission
time for 30,
90 and 180
days time
points ?
What is first
readmission
duration for
first
readmission
for 30, 90
and 180 days
time points ?
Table 4 : Healthcare utilization and patient satisfaction four weeks during counselling20,21
Characteristics Pre-test Post-test Cl value
Patients (n) 1000 1000
Length of index
hospital stay
Readmissions
Readmissions
within 30 days
Readmissions
within 60 days
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Readmissions
within 90 days
Time for first
readmission
Number of
readmissions
within 30, 60 and
90 days.
Duration of first
readmission
Other healthcare
utilization
General practitioner
visits
Emergency
department visits
Patient satisfaction
with discharge
procedure
Table 5: Programme outcome and outcome measures20,21:
Outcome Outcome measures
Clinical efficacy Whether psychiatric symptoms will be improved in the intervention
group as compared to the control group
Patient efficacy Whether intervention group will he having less number of hospital
readmissions as compared to the control group.
Healthcare staff
fidelity
Healthcare professionals execution of the programme protocol will
be evaluated:
How many post-discharge counselling sessions will be attended by
healthcare professional telephonically.
How much time healthcare professional will spend on each post-
discharge counselling session.
How much time healthcare professional will spend on weekly post-
discharge counselling session.
Success in
recruitment and
How many actually enrolled patients will be eligible for
participation in the programme.
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randomization Record will be maintained for the drop-out participants prior to
completion of the study.
Baseline characteristics of both control and intervention arm will be
compared.
Success of
counselling session
Percent participants receiving counselling session.
Percent participants attending primary healthcare providers within
two weeks of discharge.
Percent participants contacted telephonically post-discharge.
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