Impact of a Connected Care Model on 30-Day Readmission Rates from Skilled Nursing Facilities.

BACKGROUND: About one-fifth of hospitalized Medicare beneficiaries are discharged to skilled nursing facilities (SNFs) for post-acute care. Readmissions are common but interventions to reduce readmissions are scarce.

OBJECTIVE: To assess the impact of a connected care model on 30-day hospital readmission rates among patients discharged to SNFs.

DESIGN: Retrospective cohort.

SETTING: SNFs that receive referrals from an academic medical center in Cleveland, Ohio.

PARTICIPANTS: All patients admitted to Cleveland Clinic main campus between January 1, 2011 and December 31, 2014 and subsequently discharged to 7 intervention SNFs or 103 control SNFs.

INTERVENTIONS: Hospital-employed physicians and advanced practice professionals (nurse practitioners and physician assistants) visited SNF patients 4 to 5 times per week.

RESULTS: During the study period, 13,544 patients were discharged to SNFs within a 25-miles radius of Cleveland Clinic main campus. Of these, 3334 were discharged to 7 intervention SNFs and 10,201 were discharged to 103 usualcare SNFs. During the intervention phase (2013-2014), adjusted 30-day readmission rates declined at the intervention SNFs (28.1% to 21.7%, P < 0.001), while there was a slight increase at control SNFs (27.1 % to 28.5%, P < 0.001). The absolute reductions ranged from 4.6% for patients at low risk for readmission to 9.1% for patients at high risk, and medical patients benefited more than surgical patients.

CONCLUSIONS: A program of frequent visits by hospital employed physicians and advanced practice professionals at SNFs can reduce 30-day readmission rates. Journal of Hospital Medicine 2017;12:238-244.