Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions With Connection to Primary Care Within 7 Days of Hospital Discharge

Wiest D, Yang Q, Wilson C, Dravid N
Source: JAMA
Publication Year: 2019
Population Focus: Medicaid beneficiaries
Demographic Group: Adult
Intervention Type: Service redesign
Study Design: Pre-post with Comparison Group
Type of Literature: White
link: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2722571
Abstract

IMPORTANCE: 
Previous research suggests the important role of timely primary care follow-up in reducing hospital readmissions, although effectiveness varies by program design and patients’ readmission risk level.

OBJECTIVE:
To evaluate the outcomes of the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

DESIGN, SETTING, AND PARTICIPANTS:
Retrospective cohort study of hospital readmissions among Medicaid patients 18 years or older hospitalized from January 1, 2014, to April 30, 2016, in Camden, New Jersey. To assess each patient’s hospital use before and after hospital discharge, all-payer claims data from 4 healthcare systems were linked to insurers’ lists of patients assigned to Camden-based primary care practices. A total of 1531 records were categorized by timing of a primary care appointment after discharge. Discharges followed by a primary care appointment within 7 days (treatment group) were matched by propensity scores to those with less timely or no primary care follow-up (nontreatment pool).

INTERVENTIONS:
Targeted patient enrollment during hospital admission, primary care practice engagement, patient incentives to overcome barriers to keeping an appointment, and reimbursements to practices for prioritizing patients recently discharged from the hospital.

MAIN OUTCOMES AND MEASURES:
The primary outcome was the number of hospital discharges followed by a readmission within 30 days. The secondary outcome was the number of hospital discharges followed by a readmission within 90 days.

Results

    There were 2580 hospitalizations of patients 18 years and older included on the patient lists from January 1, 2014, to April 30, 2016. Of these, 1531 records categorized by timing of a primary care appointment after discharge were studied. The treatment group consisted of 450 discharged patients (mean [SD] age, 48.7 [14.7] years; 289 [64.2%] female; 203 [45.1%] black, non-Hispanic). The nontreatment pool consisted of 1081 discharged patients (mean [SD] age, 48.1 [14.9] years; 599 [55.4%] female; 526 [48.7%] black, non-Hispanic). Among this cohort, the number of discharges followed by any readmission was lower for patients with a primary care visit within 7 days of hospital discharge than for their matched referents at 30 days (57 of 450 [12.7%] vs 78.8 of 450 [17.5%]; P = .03) and 90 days (126 of 450 [28.0%] vs 174 of 450 [38.7%]; P = .002) after discharge.

    CONCLUSIONS AND RELEVANCE
    Facilitated receipt of primary care follow-up within 7 days of hospital discharge was associated with fewer Medicaid readmissions. The findings illuminate the importance of reducing barriers that patients and providers face during care transitions.

Insights Results

Overview of article

  • The objective of this study was to evaluate outcomes of a citywide campaign in Camden, New Jersey, to reduce readmissions by increasing access to timely primary care follow-up after a hospitalization. In Camden, where Medicaid covers 57% of residents (19 compared with 20% nationally), service provision is fragmented and resources are limited. Run by the Camden Coalition of Healthcare Providers (Camden Coalition), the 7-Day Pledge (7-DP) program leveraged a citywide data infrastructure, 12 primary care practices, and a care team that engaged patients while they were still in the hospital to connect them to a primary care appointment within 7 days of a hospital discharge
  • The 7-DP program addressed multiple barriers to primary care access. For patients, pre-discharge engagement to discuss the benefits of primary care follow-up and schedule visits, transportation to and from the primary care office, and a $20 gift card after appointment completion helped reduce barriers. For practices, the program offered an enhanced reimbursement on top of regular reimbursement and value-based payments: $100 for visits within 14 days and $150 for visits within 7 days were given to cover the resources required to prioritize recently discharged patients. Camden Coalition staff met monthly with each practice to review the 7-DP data and discuss strategies for improving program implementation
  • Authors concluded timely connection to primary care after a hospital discharge creates opportunities to discuss medication changes and other discharge instructions outside the hospital setting, potentially reducing readmission risk
    Methods
  • This was a retrospective cohort study of hospital readmissions among Medicaid patients 18 years or older hospitalized from January 1, 2014, to April 30, 2016, in Camden, New Jersey
  • To assess each patient’s hospital use before and after hospital discharge, all-payer claims data from 4 health care systems were linked to insurers’ lists of patients assigned to Camden-based primary care practices. A total of 1531 records were categorized by timing of a primary care appointment after discharge. Discharges followed by a primary care appointment within 7 days (treatment group) were matched by propensity scores to those with less timely or no primary care follow-up (nontreatment pool)

Results

  • Outcomes assessed included number of discharges followed by rehospitalizations within 30 or 90 days. Authors found an association between 7-DP and reduced hospital readmissions for adult Medicaid patients in Camden, New Jersey. At 30 and 90 days after a hospital discharge, patients who attended a primary care appointment within 7 days of discharge had fewer readmissions compared with patients with a later primary care visit or none
  • The 7-DP program components include: 1) Meeting with practices monthly to assess progress; 2) Prioritizing relationship building with practice staff at all levels; 3) Incentivizing practices to free up timely appointments for patients leaving the hospital; 4) Launching promotional campaigns to build momentum for 7-DP; and 5) Holding quarterly accountable care organization dinners during which program staff shared results and strategies with providers and other community members

Key takeaways/implications

  • Timely connection to primary care after a hospital discharge creates opportunities to discuss medication changes and other discharge instructions outside the hospital setting, potentially reducing readmission risk. Programs such as the 7-DP may be associated with a reduction in preventable hospital admissions through patient and practice engagement, providing incentives to patients to overcome barriers to keeping an appointment, and adequately reimbursing practices on top of regular reimbursement and value-based payments to prioritize appointments for recently discharged patients
  • Limitations include: 1) Social risk variables not factored into study; 2) Strength and quality of relationships between providers and patients; 3) Consistency of Medicaid coverage over time; and 4) The program was unable to compare data about primary care follow-up rates before the program
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