Transitional Home Care Program Utilizing the Integrated Practice Unit Concept (THC-IPU): Effectiveness in Improving Acute Hospital Utilization.

BACKGROUND: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation.

METHODS: 1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.

RESULTS: We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders.

CONCLUSION: Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions.