ComplexCaseConferencesAssociatedwithReducedHospital AdmissionsforHigh-RiskPatientswithMultipleComorbidities

Objectives:� Reducingavoidablehospitalreadmissionspresentsanopportunityto� improvehealthcarequalityandreduceavoidablecosts.�Westudiedtheeffectperson- focusedcaremayhaveonreducingavoidableadmissionstothehospital.� Methods:�Amongpatientswithheartfailuredischargedfromthehospital,�weevalu- atedtheeffecton�30-dayreadmissionsoftransitions-in-careinterventions:�homehealth� visits,�follow-upphonecalls,�andphysicianofficevisits.�Wealsousedastandardized� diagnostictooltointerviewreadmittedpatientstoidentifysocialreasonsthatmayhave� contributedtothereadmission.�Finally,�weusedthelearningsfrombothinterventions� todevelopanewintervention:�asinglecomplexdiseasecaseconferencethatincluded� theentirehealthcareteam.�Wemeasuredhospitaladmissionsfor�21�patientsduring� the�6�monthsbeforeandaftertheircomplexcaseconferences.� Results:�Observed-over-expectedhospitalreadmissionrateswerelowestforpatients� receivingapostdischargevisitwithahomehealthnurseandafollow-upvisitwiththeir� physician�(0.54),�comparedwithsolelyaphysicianvisit�(0.81),�homehealthvisit�(1.2),� orphonecall� (1.55).�Varioussocialissuesmaycontributetohospitalreadmissions,� includingcaregiverknowledge,�abilitytocareforoneselfathome,�andissuesrelated� tomedications�(adherence,�abilitytopay,�andknowledgeaboutpotentialsideeffects).� Substantiallyfewerhospitaladmissionsoccurredaftercomplexcaseconferences.� Conclusions:�Complexcaseconferenceswithdisease-focusedandperson-focused� interventionsmaybeassociatedwithreducedhospitaladmissionsforpatientswithheart� failureandmultiplecomorbidities.�