Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates

Abstract

Care transition programs can result in cost avoidance and decreased resource utilization. This project aimed to determine whether implementation of a discharge clinic, referral to a community paramedicine program, or a second postdischarge call affected 30-day readmission rates. This single-center retrospective exploratory design study included 727 discharged patients without access to a primary care provider who were scheduled for a discharge clinic transitions appointment. Readmission rates were 17.7% for those who completed a discharge appointment and 24.7% for those who did not; 4% for those completing a second postdischarge call and 26% for those who did not; and 11.1% for those referred to a community paramedicine program and 24.9% for those not referred. A completed discharge clinic appointment resulted in 36% lower odds of readmission. A completed discharge clinic appointment was effective in reducing 30-day readmission rates as was a follow-up call.

Introduction

Patients transitioning from an inpatient hospital stay to self-care responsibilities postdischarge are at risk for 30-day readmission, especially when nonmedical drivers of health are unmet.¹ Hospital 30-day readmissions result in increased cost and resource utilization as well as a decreased quality of life for the patient. The complexity and intensity of interventions for patients with multiple chronic conditions represent a challenge and patients often struggle to obtain the required care after an acute illness.²

Chakravarthy et al³ determined a 3 times higher rate of 30-day readmissions among Medicare and Medicaid patients when they did not attend a transition-of-care (TOC) appointment. Care transition programs can result in cost avoidance of nearly $4000 per patient over 6 months while decreasing acute health care resource utilization.⁴

Care transition programs focus on patient-centered interventions (self-management, education, skills, provider training, care/case management) that have the potential to positively impact chronic disease outcomes.⁵ The greatest potential for improvement of primary and secondary outcomes in older adults with multimorbidities has been seen with care coordination interventions focused on how, who, when, and where health care is organized and delivered.^1,6

In a 2018 survey of US physicians, 90% reported their patients were affected by 1 or more nonmedical drivers of health.⁷ With more than 80% of a person's health outcomes affected by nonmedical drivers of health, patient care requires a switch in focus from the traditional focus on “clinical care” to a focus on social, economic, and environmental factors. With the transition to value-based care, population health efforts focused on addressing nonmedical drivers of health are viewed as essential to providing cost-effective care.⁸

However, population health approaches should be focused on solving the problem at hand for each individual patient instead of providing a one-size-fits-all approach. Evidence-based and scalable interventions that provide early identification of health concerns improve outcomes and downstream spending as does having a strong infrastructure that can support such programs outside of the clinical care system.^9,10

A scoping review of effective elements in patient-centered care among patients with comorbidities indicated that innovative programs positively affect health-related outcomes.⁵ Overall, findings support care transition programs as a promising approach for managing and improving chronic disease outcomes and resource utilization, especially when focused on symptom reduction and preserving the quality of life.^1,6 With the transition to value-based care, organizations must embrace care redesign to improve care delivery and health care savings.

A TOC model implemented in a family & community medicine (FCM) clinic at the University of Kentucky Healthcare (UKHC) showed a reduction in 30-day readmission rates among those patients attending a TOC appointment.¹¹ The clinic's TOC program further discovered that patients without a primary care provider or an external (outside the system) primary care provider were at greater risk of 30-day readmission than patients with a system primary care provider.¹² The success of this program paved the way for the implementation of a Population Health Service (October 2020)^11,12 and a subsequent discharge clinic (November 2021). The Population Health Service was then able to scale its TOC program systemwide wide to the rest of the adult primary care clinics.

Along with TOC programs, community paramedicine programs have emerged across the United States (and other countries) to address the need for health care reform, especially among vulnerable populations.^13,14 Community paramedicine programs expand the role of paramedics beyond emergency response and transport and have the potential to reduce the utilization of emergency departments and 30-day readmission rates. These programs also serve as a community liaison between the patient, community resources, and the health care system. Paramedics are trusted health care providers within communities that allow for a community-driven approach.^13,14

Follow-up after discharge through a clinic visit has been shown to lead to decreased 30-day readmissions;^{1,3,15

–18} alternately an increased risk of 30-day readmission occurs when patients do not complete a discharge clinic visit.^1,3,15 Most of the clinic designs included a team-based care approach and employed varying teams including a provider, registered nurse, social worker, medical assistant, clinical pharmacist, and patient navigator.^1,3,15
–17

Gaps in knowledge in the literature in relation to discharge appointments include, “Does having an appointment scheduled before discharge affect a patient's likelihood of attending a discharge appointment” or “Does a patient's engagement in care affect 30-day readmission rates.”^16,18 An additional question was, “For those patients who did not show up to the discharge clinic appointment, were social drivers of health a factor?”

The purpose of this project was to determine whether implementation of a discharge clinic improved 30-day readmission rates in patients who did not have a primary care provider or did not have access to their primary care provider. Second, whether a visit from the community paramedicine program impacted 30-day readmission rates in patients who missed their discharge clinic appointment and whether a second postdischarge phone call from a licensed practical nurse affected 30-day readmission rates.

Methods

Design

This was a single-center, retrospective exploratory study focused on 30-day readmission rates for adult patients. Evaluation of the 30-day readmission rate for the discharge clinic included the timeframe of November 2021 to November 2022. This study was reviewed and approved by the University of Kentucky Institutional Review Board.

Setting and participants

This study took place at an academic medical center in the south-central part of the United States. The discharge clinic within this organization was designed to provide a centralized location for hospital follow-up for those patients who did not have a Primary Care Provider (PCP) or access to their PCP. Patients referred to the discharge clinic typically were at higher risk of 30-day readmission based on Epic's Risk of Unplanned Readmission risk score of 14 or greater.¹⁹ The discharge clinic employed 1 physician, 2 nurse practitioners, 2 registered nurses, 2 medical assistants, and 1 clinic manager. The clinic offers a comprehensive hospital follow-up visit that can include laboratory and imaging services, wound care, intravenous treatment (fluids, diuresis, antibiotics, etc.), breathing treatments, spirometry, etc.

The sample population for this study included adult patients without a primary care provider or patients without timely access (within 7–14 days postdischarge) to their primary care provider for a hospital discharge follow-up appointment who were scheduled for an appointment in the discharge clinic. Patients referred to the discharge clinic typically had a 30-day readmission risk score of 14 or greater, but patients with a lower risk score were also included if they were scheduled for an appointment in the discharge clinic. It is worth noting that while an algorithm was used to identify patients for the discharge clinic, patients might have been included or excluded erroneously.

For example, providers could place an order for the discharge clinic outside of the established algorithm allowing patients with a readmission risk score of less than 14 to be referred to the discharge clinic. Theoretically, providers could have also removed the automatic referral to the discharge clinic, meaning some patients may not have received a discharge clinic appointment. The total number of patients scheduled in the discharge clinic for a TOC appointment between November 2021 and November 2022 was 727. This number included only those patients who attended (arrived) or did not attend (no showed) their TOC appointment.

Procedure

Intervention

In November 2021, the organization opened the discharge clinic, which provides patients who do not have a primary care provider or access to their primary care provider a centralized location for a hospital discharge follow-up within 7–14 days. The Population Health Service expanded its TOC program to the discharge clinic at that time. Approximately 6- and 10-month post-go-live of the discharge clinic, quality improvement initiatives were implemented to further help reduce 30-day readmission rates. These quality improvement initiatives expanded the collaboration the organization had with the community paramedicine program as well as expanded the role of the Population Health Services' TOC program.

The discharge clinic, designed to provide care to those patients at a higher risk of 30-day readmission, found some of the highest risk patients were missing their TOC appointments. The organization's Population Health Service decided to collaborate with the community paramedicine program to improve outcomes for high-risk patient populations. The Population Health Service referred patients who missed their TOC discharge clinic appointment to the community paramedicine program.

The community paramedicine program did not have the capacity to see all patients who missed their discharge clinic appointments and could not see patients outside of Fayette County. The inclusion criteria for referral to the community paramedicine program included the patient must reside within Fayette County, there must be an address associated with the patient in the electronic medical record, and the Population Health Service could refer no more than 5 patients per month. The community paramedicine team visited these patients in the community to determine further needs of the patient and to help with care coordination activities.

The community paramedicine program attempted to see all patients referred to them but could not always locate or connect with the patient to complete a home visit. This quality improvement initiative started in May 2022.

Patients answering an initial TOC call (24–48 hours after discharge) from the Population Health Service were enrolled in the TOC program for 30 days, which created an opportunity for a second quality improvement initiative. The Population Health TOC program started calling enrolled patients 7–10 days after their completed discharge clinic appointment to continue care coordination services. Three attempts were made to reach the patient on different days and at different times throughout the day. This allowed for the continued care of patients while they awaited primary care provider follow-up. This quality improvement initiative started in September 2022.

Data analysis

Descriptive statistics were used to analyze demographic and readmission data. A chi-square and Fisher's exact test were used to determine whether there was an association between a discharge clinic visit and 30-day readmission, a second postdischarge clinic appointment phone call and 30-day readmission rates for those patients who attended their discharge clinic appointment, and a paramedicine visit and 30-day readmission rates for those patients who did not attend their discharge clinic appointment. Linear regression modeling was used to evaluate the association between discharge clinic visit completion and 30-day readmission, adjusting for gender, race/ethnicity, and payor status. SPSS version 27 was used for data analysis and statistical significance was considered with a P-value ≤0.05.

Results

The mean age of the participants was 53.49 years (standard deviation 15.75) with the majority being male (58.7%), White (71.4%), and non-Hispanic (92.4%) (see Table 1). Medicaid was the largest payer source (46.4%) followed by Medicare (33.9%) and commercial sources (13.7%). Only 4.5% were self-pay.

Table 1.

Demographic Summary of Discharge Clinic (N = 727)

Variable
Age, mean (SD)	53.49 (15.75)
Gender, n (%)
Male	427 (58.7)
Female	300 (41.3)
Race, n (%)
Black or African American	167 (23)
White	519 (71.4)
Other	41 (5.6)
Ethnicity, n (%)
Hispanic	53 (7.3)
Non-Hispanic	672 (92.4)
Declined to answer	2 (0.3)
Payor, n (%)
Commercial/private	100 (13.7)
Medicaid	337 (46.4)
Medicare	246 (33.9)
Self-pay	33 (4.5)
Other	11 (1.5)

SD, standard deviation.

For the 727 patients who had scheduled appointments in the discharge clinic, 452 patients (62.2%) completed their appointment, while 275 patients (37.8%) did not complete their appointment (see Table 2). One hundred forty-eight (20.4%) of 727 patients scheduled for a discharge clinic appointment were readmitted within 30 days of discharge, whereas 579 (79.6%) did not experience a 30-day readmission.

Table 2.

Appointment Outcomes and Readmissions of Discharge Clinic (N = 727)

Variable	n (%)
Appointment outcome
Completed	452 (62.2)
No show	275 (37.8)
Readmissions
Not readmitted	579 (79.6)
Readmitted	148 (20.4)

For patients who completed a discharge clinic appointment (n = 452), 17.7% were readmitted within 30 days compared with 24.7% for those who did not complete their discharge clinic appointment (n = 275; P = 0.022; see Table 3). A bivariate analysis demonstrated that the only variable significantly associated with readmission status was appointment outcome (completed appointment vs. did not complete; P = 0.023). In the logistic regression model, adjusting for gender, race, ethnicity, and payor sources, those who completed the discharge clinic appointment had 36% lower odds of readmission than those who did not complete the discharge clinic appointment (odds ratio = 0.64, 95% confidence interval = 0.44–0.92, P = 0.017).

Table 3.

Readmission Rates of Discharge Clinic

	Readmitted, n (%)	Not readmitted, n (%)	P
Discharge clinic appointment status (n = 727)			0.022
Completed	80 (17.7)	372 (82.3)
No show	68 (24.7)	207 (75.3)
Among no show (n = 187)			0.251
Paramedicine visit	2 (11.1)	16 (88.9)
No paramedicine visit	42 (24.9)	127 (75.1)
Among completed (n = 144)			<0.001
Follow-up call	2 (3.8)	51 (96.2)
No follow-up call	24 (26.4)	67 (73.6)

From September 2022 to November 2022, TOC calls were initiated for patients who had completed a discharge clinic appointment (n = 144). This postdischarge clinic appointment call was completed for 53 patients (36.8%), whereas 91 (63.2%) did not answer the second TOC call. For those patients who completed a second TOC call, there was a 3.8% readmission rate compared with 26.4% for those who did not complete a second TOC call (P < 0.001).

Between May 2022 through November 2022, a community paramedicine home visit was implemented for those patients who did not complete a discharge clinic visit (n = 187). Of the 187 patients who did not complete a discharge clinic appointment, 18 patients (9.6%) were referred to the paramedicine program and received a home visit while 169 (90.4%) were not referred. The readmission rate for those patients visited by the community paramedicine program was 11.1% compared with 24.9% for those not seen by the paramedicine team (P = 0.251).

Discussion

The purposes of this project were to determine whether implementation of a discharge clinic improved 30-day readmission rates in patients without access to a primary care provider, whether a visit from the community paramedicine program paramedic impacted 30-day readmission rates, and whether a second postdischarge call affected 30-day readmission rates. The discharge clinic was designed to provide a centralized location for hospital follow-up for those patients who did not have a PCP or timely access to their PCP. Referral criteria to the discharge clinic targeted high-risk patients admitted to the hospital.

Hence, patients referred to the discharge clinic typically were at much higher risk of 30-day readmission based on Epic's Risk of Unplanned Readmission risk score of 14 or greater compared with the general admitted patient population.¹⁹ This suggests a higher complexity of patients, as does the propensity for not having a PCP or access to their PCP for discharge follow-up.¹²

The results from this study provide preliminary evidence that completing an appointment in the discharge clinic may improve readmission rates for high-risk patients. It is important to note this high-risk patient population generally has a higher 30-day readmission rate than the general population, prompting referral to the discharge clinic. The readmission rate for completed discharge clinic appointments was 17.7%, which was lower than the 24.7% readmission rate for those patients who did not complete a discharge clinic appointment. Data analysis showed statistical significance for a reduction in 30-day readmissions when a patient completed their discharge clinic appointment.

In addition, a completed discharge clinic appointment was the only variable significantly associated with reducing 30-day readmission, which is consistent with previous studies.^{1,3,11,15

–18}

Eighty percent of the patient population had either Medicaid (46.4%) or Medicare (33.9%) that increases the risk of 30-day readmission³ as does their risk for nonmedical drivers of health.¹ Payer source, race, nor ethnicity had a significant impact on 30-day readmissions in this study. Regardless of gender, payer source, race, or ethnicity, patients who completed their discharge clinic appointment had 36% lower odds of 30-day readmission. Ballard et al¹¹ reported similar findings regarding age, but Chakravarthy et al³ reported patients with Medicare or Medicaid had 3 times higher odds of readmission.

Since paramedics are trusted by community members, collaborating with the community paramedicine program provided further care coordination opportunities.^13,14 Unfortunately, the referrals to the community paramedicine program were limited by the capacity of the program to take on added patients. The 30-day readmission rate for patients seen by the community paramedicine program was lower (11%), although this was not statistically significant. Further data collection and analysis are needed to determine whether this intervention truly has the potential to impact 30-day readmission rates in this patient population. Nevertheless, the findings from this study suggest that traditional hospital follow-up may not be the only way to reduce hospital readmissions.

The second intervention consisted of a second TOC call 7–10 days after the completed discharge clinic appointment. Schaeffer et al² stated patients struggle to obtain needed care posthospitalization and the second TOC call allowed care coordination efforts to continue between the discharge clinic appointment and the next follow-up appointment. Results showed a readmission rate of 3.8% for this patient population. It is worth noting only 37% of the patients were reached for a second TOC call. Although 63% of the patients did not answer the second TOC call, the 3.8% 30-day readmission rate was statistically significant.

It is also worth noting the 30-day readmission rate for those patients who did not complete their discharge clinic appointment was slightly lower than those patients who completed a discharge clinic appointment and did not complete a second TOC call (24.7% vs. 26.4%). For those patients who did not complete a discharge clinic appointment, they may have felt well after discharge prompting them to not attend their appointment or they may have followed up outside of this organization for a discharge appointment or emergency room visit. The risk of readmission or nondrivers of health may have also been different for the patients who fell into these populations.

This speaks of the challenges Baldino et al¹ shared regarding how to determine the needed level of complexity and intensity of interventions implying interventions focused on how, who, when, and where health care is organized and delivered may have the greatest potential to improve outcomes.^1,6

Health outcomes are driven by multiple factors, and studies suggest that the primary drivers of health and health behaviors are related to social and economic factors²⁰ that include race or ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location.²¹ Over the past 2 decades, complex relationships between many factors led to the realization that the absence of disease does not necessarily mean good health. These complex relationships include “health and biology, genetics, and individual behavior, and between health and health services, socioeconomic status, the physical environment, discrimination, racism, literacy levels, and legislative policies” and are known as determinants of health.

These factors contribute to the conditions in which people live, and, to some extent, explain why some Americans are healthier than others or why some Americans are not as healthy as they could be.²¹ Although this study implies a discharge clinic visit and a second TOC call may decrease the risk of 30-day readmission, it is important to note this does not imply causality. Nonmedical drivers of health have a significant effect on patient outcomes,²⁰ and randomized control trials could help determine causality especially when controlling for confounding variables.

The patient population was not comprised of patients with a specific disease state but included all comorbidities, making it hard to translate these findings to specific disease states or patient populations. The fact that the discharge clinic typically sees high-risk patients also decreases the ability to generalize results to the general patient population, which was a project limitation.

Implications

Based on the findings of this study, there are implications for practice that warrant consideration. An example would be to expand the collaboration with the community paramedicine program. Although a visit from the community paramedicine team did not result in a statistically significant reduction in readmissions, it did show promise in reducing 30-day readmission rates. Expanding this pilot study by providing capacity for the community paramedicine program to accept more referrals could determine whether future collaboration with the community paramedicine would improve 30-day readmission rates.

Another consideration for practice would be to determine whether to continue the second TOC call. Although the second TOC call resulted in a statistically significant reduction in readmissions, only 37% of the patients were reached, which means 63% were not reached. This is a large number, but considering the reduction in readmission rate, it makes sense to continue this work until other interventions are vetted. One such intervention to consider is text messaging in addition to phone calls. Further research could be conducted to determine whether more people or certain patient populations are reached by adding text messaging capability.

Further analysis could determine whether or not text messaging affects the ability to reach patients for a second TOC call and subsequent 30-day readmission rates. Ideally, a patient's preferred method of communication would be assessed at registration and used as the patient's chosen method of communication.

Future research on the discharge clinic patient population should also address the following: (1) nonmedical drivers of health, (2) whether the follow-up appointment should be made before or after discharge from the hospital, (3) the timeframe for the follow-up appointment, (4) the impact of an initial TOC call (made within 48 hours of discharge), (5) the patients' level of engagement in their care, (6) the patient's prior interaction with the health care system, and (7) PCP status to determine whether these factors affect appointment outcome and 30-day readmission rates.

A completed appointment in the discharge clinic had a statistically significant impact on reducing readmission rates, so determining the root cause of the 37.8% who did not complete their discharge clinic appointment might be valuable in determining interventions that could reduce the no-show rate for the discharge clinic and subsequently improve 30-day readmission rates.

Being able to translate findings into action is imperative as the health care landscape continues to change. Value-based programs focus on prevention and care coordination. Implementing asynchronous care that includes collaboration across intra- and interprofessional teams focused on patient-centered interventions has the potential to improve access to preventive services and positively impact chronic disease outcomes. Population health interventions also have the potential to provide efficient and effective care that addresses upstream barriers to providing care in the least restrictive and least expensive manner. This shift in care delivery can also reduce resource utilization and lower overall health care.⁸

Finances are a significant focus for organizations. Value-based care programs have called for action related to reducing the cost of health care. The TOC program is a revenue-generating program that can offset the cost of employing nurses who make the TOC calls. Further data analysis could help determine the full extent of the ROI. Knowing a completed TOC appointment is a significant factor in reducing 30-day readmission rates, future research should focus on determining why 38% of the patients no showed their appointment. This could lead to further cost savings and an overall reduction in health care costs.

Conclusion

A completed discharge clinic appointment was effective in reducing 30-day readmission rates as was a second TOC call. The community paramedicine program collaboration showed promise in reducing 30-day readmission rates although further research is needed. This study also indicated asynchronous patient-centered interventions focused on how, when, and where care is delivered have the potential to reduce readmission rates. A reduction in the 30-day readmission rate was a measure of success, but further research is needed to determine which interventions have the greatest impact. Identifying interventions that have the greatest impact and improve 30-day readmission rates is imperative for improving outcomes, reducing resource utilization and health care costs, and avoiding penalties in value-based programs.

Footnotes

Acknowledgment

This project was completed as part of a DNP program: Dr. Sass, Doctor of Nursing Practice, 2023, University of Kentucky, UKnowledge, 413. https://uknowledge.uky.edu/dnp_etds/413

Authors' Contributions

Dr. Sass. contributed to writing original draft, data curation, conceptualization, and methodology. Dr. Hampton and Dr. Cardarelli were involved in conceptualization and writing, review, and editing. Dr. Edward contributed to writing, review, and editing.

Author Disclosure Statement

The author(s) declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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