Early follow-up reduces readmissions of high-risk patients

Prompt follow-up care for high-risk patients with multiple chronic conditions significantly reduces their risk of readmission, according to a new study published in the Annals of Family Medicine.

Researchers, led by Carlos Jackson, Ph.D., of Community Care of North Carolina, Raleigh, analyzed 44,473 North Carolina Medicaid recipients with 65,085 qualifying discharges. They found that readmissions fell among one in four patients if the patient had an outpatient visit within a week of discharge, but reductions were negligible for the rest.

"Most patients do not meaningfully benefit from early outpatient follow-up. Transitional care resources would be best allocated toward ensuring that highest risk patients receive follow-up within seven days," Jackson wrote. Jackson and his team further found the benefit of following up earlier with patients increased with patients' readmission risk.

Patients at each level of readmission risk had a lower risk if they followed up within two weeks of discharge, with the reduced risk ranging from 1.5 percentage points to as high as 19.1 points. They also found, however, that only slightly more than half of the patients in the three highest levels of risk received follow-up care within a two-week period, which was roughly the same proportion as lower-risk patients.

Follow-up care within seven days reduced readmission risk between 6.2 and 7.7 points among the highest-risk patients, according to the story. Controlling for age, sex and race of patients and excluding behavioral health admissions led to similar results. 

The findings, Jackson and his team wrote, indicate providers may choose a "one-size-fits-all" approach over evidence-based strategies or individual care needs. Changes in reimbursement policies are likely to drive further changes in transitional care, according to the study, although recent research indicates hospitals may still face financial penalties even if they meaningfully reduce readmissions.

To learn more:
- here's the study abstract

 

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