Abstract
Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners’ efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.
A common patient goal for postacute care (PAC) rehabilitation is a successful community discharge: getting home and staying home without a readmission into the health care system (Xian et al., 2015). Policymakers and health care insurers have been emphasizing safe and effective patient transitions to the community as a strategy to improve patient outcomes and control health care costs given that the current health care system provides little incentive to coordinate care to prevent readmissions or use PAC efficiently (Ackerly & Grabowski, 2014).
The Centers for Medicare & Medicaid Services (2015b) 30-day hospital readmission measure was the first value-based payment outcome that linked hospital performance to payment. Under value-based initiatives, PAC services are of significant interest as hospitals and health systems look to reduce costs, improve quality, and develop clinical delivery networks. Recent policies have broadened the scope of care transition quality measurement to include PAC explicitly. For instance, the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185) has statutory requirements for quality-reporting programs that include 30-day hospital readmissions for all PAC settings, including skilled nursing, inpatient rehabilitation, home health, and long-term acute care. As a result, PAC providers will need to examine their current practices and engage in quality-improvement efforts to optimize patient outcomes and avoid financial penalties for poor performance.
In the context of value-based payment models (e.g., accountable care organizations, the comprehensive care for joint replacement bundling initiative), hospitals are selecting PAC providers on the basis of performance. As a result, PAC facilities are being asked to present data on the quality and outcome of their care as health care provider relationships are established across the care continuum. Therefore, there is a need to identify best practices so PAC providers and clinicians can deliver high-quality care and prevent readmissions.
A growing body of research has been examining effective care transition to the community from acute care. Yet, little is known about effective interventions for facilitating a safe and effective transition to the community from PAC. Unlike patients discharged from the hospital to the community, PAC patients have continuing medical and functional care needs that facilitated their initial admission to a PAC setting after hospital discharge (Leland et al., 2015). This accumulation of care needs suggests that PAC patients and their caregivers may need to be equipped with additional tools to manage the community care transition. For example, accidental falls are a common adverse event that occurs in the initial transition to the community after PAC, often resulting in a readmission (Davey et al., 2004; Johnston et al., 2010).
Studies have also documented the emotional difficulties patients and caregivers face during the transition process. Patients struggle to reconcile their expectations of themselves with their altered functional capacities after PAC (Wood et al., 2010). Caregivers report feeling unsupported in their new role as the primary caregiver, excluded from the health care decision-making process, ill trained in the skills necessary to care for the patient at home (e.g., fall prevention, patient handling), and uninformed about the recovery process and signs of medical or functional exacerbations that may result in a rehospitalization (Brereton & Nolan, 2000; Davey et al., 2004; Ellis-Hill et al., 2009). Moreover, patients and caregivers report not knowing whom to contact when questions arise after discharge or how to navigate the health care system (Mackenzie et al., 2007). These stakeholder perspectives are reinforced by research documenting the common occurrence of failed community care transitions from PAC (Leland et al., 2015; Ottenbacher et al., 2014). Thus, by examining the current community care transition literature and placing these findings in the context of PAC patient and caregiver transition needs, PAC community transition initiatives can be evaluated, and patient rates of successful community discharge can be optimized.
Given the broader health care context and the unmet needs of PAC patients and caregivers as they transition to the community, it is important for PAC practitioners to take an active role in the development, evaluation, and implementation of community transition initiatives. Thus, the purpose of this scoping review was to summarize current community transition interventions that can inform future initiatives to enhance PAC care transitions by focusing on improving the quality of these transitions while preventing hospital readmissions. Given the continued growth of value-based payment throughout the health care system, these findings will guide future research, education, and practice as PAC health care practitioners are challenged to demonstrate their contribution to optimizing successful community discharges and preventing readmissions.
Method
We used a scoping review approach to answer the question, “What is the current evidence for community transition interventions that can inform the role of occupational therapy in preventing readmissions?” Unlike a systematic review, which evaluates the quality of the literature, a scoping review summarizes the range of evidence on a given topic and identifies gaps in the literature to guide future research needs (Arskey & O’Malley, 2005).
The search comprised articles published between 2000 and 2015. Preliminary searches indicated that readmission research began to develop in 2000. This was also the time when quality reporting emerged in the United States with the establishment of the National Quality Forum in 1999 and the 2002 start of the Nursing Home Quality Initiative (Centers for Medicare & Medicaid Services, 2015a), which includes the publicly available measures published on the National Quality Forum website (http://www.qualityforum.org/about_nqf/history/). Included articles had to be written in English, be published in peer-reviewed journals, assess a community transition intervention from an institutional health care setting, and evaluate readmission as an outcome. International studies were included to capture the broad scope of community transition interventions. Systematic reviews and meta-analyses were excluded to ensure that the research team could extract individual care processes included in each intervention study. However, the reference lists of these articles were reviewed to identify any relevant articles not already captured by the initial search. MEDLINE, PubMed, CINAHL, and OTseeker were used to conduct the bibliographic search.
The terms used in the database search included care transitions, readmission, and community transition. Targeted searches for established care transition programs, such as Adams et al.’s (2014) Project RED, Coleman et al.’s (2006) The Care Transition Program®, and Naylor et al.’s (2004) Transitional Care model, were also conducted. This approach resulted in an initial sample of 1,199 articles. The removal of duplicates and initial screening of titles and abstracts reduced the sample to 108. These articles were appraised to ensure that initial inclusion criteria were maintained, resulting in the exclusion of 73 additional articles.
The research team excluded community-based interventions that solely targeted prevention of an initial admission to the hospital, such as those implemented through primary care offices or health insurance plans (n = 11). This decision was implemented to ensure that the team was capturing interventions that targeted patients in active recovery after an acute medical event. The primary care chronic disease management interventions that target hospital admissions may be informative for future PAC interventions; however, this literature was outside the scope of this study. Other exclusions included cost-effectiveness evaluations (n = 6); subanalysis of an intervention already included in the sample (n = 2); process evaluations of quality improvement projects (n = 6); absence of a readmission measure (e.g., frequency, rate, risk, or time to readmission) being included as a primary outcome (n = 19); and intervention studies outside the scope of occupational therapy, such as medication efficacy (n = 29).
Data from the final sample of articles were then extracted for charting the studies (e.g., method, setting, and core components of the intervention). Two researchers (blinded for review) independently reviewed the core components of the interventions and established common themes across studies. These two then met, discussed the themes, and came to a consensus on the care process themes that would characterize the final sample. Each intervention was reviewed in the context of the care process themes to capture the range and scope of transition practices. Discrepancies were deliberated among the researchers until a consensus was achieved. Data were then descriptively analyzed to present a summary of the method, settings, and interventions.
Results
Supplemental Table 1 (available online at https://otjournal.net; navigate to this article, and click on “Supplemental”) contains an overview of the 35 articles included in this study. Twenty-four (68%) of the included studies were randomized control trials. Thirty-four studies (97%) were initiated in acute care settings, and 1 was initiated in a skilled nursing facility. The most common patient populations targeted for readmission interventions were those admitted to a cardiac unit (n = 7; 20%) or a medical–surgical unit (n = 9; 26%) and participants age 65 yr or older (n = 9; 26%). Twenty-eight (80%) studies were conducted in the United States, and 7 (20%) were conducted elsewhere.
Care Process Themes
Supplemental Table 2 (online) presents the distribution of the 13 care processes themes across the 35 articles. The number and scope of care practices included in each intervention varied. For instance, Wong and collaborators (2008) used a single home visit and follow-up phone calls, whereas Courtney and colleagues (2009) used a multicomponent intervention consisting of 12 care practices. Despite the variation in intervention components, there were 5 frequently used care processes, 4 of which were included in 74% of the studies (medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up). Care transition coaching and education were included in 60% of the studies.
The effect of the interventions on preventing readmissions also varied. Eighteen (51%) studies found that the treatment group had significantly fewer readmissions at follow-up than the comparison group, and 12 (34%) studies found no significant difference between the groups. Four (11%) had mixed results based on the time at which the readmission outcomes were captured: 30, 60, 90, and 180 days. Although no single care process appeared consistently across all 18 effective interventions, 12 studies (67%) included some combination of at least four of the five most frequently used care processes (i.e., medical self-management, medication self-management, scheduling follow-up medical services, telephone follow-up, care transition coaching and education). Finally, although a variety of disciplines were involved in the 35 studies, none of the interventions included an occupational therapist (Supplemental Table 3, online).
Evaluation of Readmission Risk
Twelve studies assessed readmission risk to identify patients at high risk for readmissions and connect them with appropriate care transition interventions; 8 (23%) studies included a comprehensive assessment, and 4 (11%) studies screened for readmission risk. Amarasingham and colleagues (2013) completed the risk assessment close to the time of admission to ensure that a tailored care transition intervention was delivered throughout the hospital stay. One or more disciplines contributed to the comprehensive assessment to capture a holistic picture of the patient’s and caregiver’s transition needs (Courtney et al., 2009). An alternative approach was to conduct a targeted assessment within 72 hr of discharge to identify potential barriers and facilitators to a successful community transition (Park et al., 2013; Wong et al., 2011). Researchers used different evidence-based approaches to identify patients at risk of a readmission, such as a risk factor checklist (Balaban et al., 2015; Courtney et al., 2009) and an algorithm embedded within the facilities’ electronic medical record, which integrated key items documented in the chart to quantify risk (Altfeld et al., 2013).
Preparing for Community Discharge
The results of a risk assessment revealed that multidisciplinary discharge planning with patients and families was used in 8 (23%) studies. A common approach was to equip the patient and caregiver with new skills to understand the transition process, find available community resources, and manage the patient’s health. Educating the patient and caregiver was done by means of a variety of disciplines, including care transition coaches, case managers, nurses, physical therapists, and community health workers (see Supplemental Table 3, online). The frequency of the education or coaching sessions ranged from one session within 72 hr of discharge (Park et al., 2013) to multiple sessions. In Sethares and Elliott’s (2004) study, sessions were initiated on the day of hospital admission, spanned throughout the hospitalization, and continued after the patient had returned to the community. In addition to conveying information, 6 studies (17%) integrated hands-on training or teach-back methods, or both, to ensure that the patient and caregiver could recall, model, and carry out the strategies in the community. Parry and colleagues (2009) used care transition coaching to empower patients and caregivers to effectively communicate with their health care providers. Courtney and colleagues (2009) used training and teach-back methods in the hospital to facilitate carryover and execution of an exercise program after the transition.
The content of the education and skill-building sessions varied by study population, but the core themes of the content included (1) understanding what to expect during the transition process; (2) developing skills related to the medical diagnosis, including disease management, recognizing exacerbations, which Coleman and colleagues (2006) termed red flags, and actions to take when symptoms arose; (3) fostering medication reconciliation or self-management skills; and (4) providing information on community resources to support the patient and caregiver in the long-term management of the disease and overall health (e.g., Meals on Wheels, assistance with activities of daily living).
Postdischarge Follow-Up
As the discharge date approached, a key intervention component was facilitating a seamless hand-off between the health care institution and the community provider(s). The most common strategies for the hand-off were scheduling follow-up appointments and services, providing patient-centered discharge documents and medical charts (i.e., documents tailored to the patient’s unique needs, which can be updated and used by the patient to communicate with subsequent providers), and making follow-up phone calls and home visits. The discharge form used by Balaban and colleagues (2008) included discharge diagnoses, vaccine summary, provider names, new allergies, dietary and activity instructions, home health orders, scheduled appointments, pending medical results, recommended outpatient workup, a discharge medication list, nursing comments, and a reminder to bring the forms to the next visit to the primary care physician. The discharge summary with the details of the patient’s recent hospitalization was faxed or sent electronically to primary care providers (Balaban et al., 2008; Berkowitz et al., 2013; Casas et al., 2006; Dedhia et al., 2009). The intent of giving the patient-centered medical chart to the patient and caregiver, instead of sending it to the physician, was to empower the patient (and caregiver) with information about his or her own care to use in communications with the community providers.
To further reinforce new medical management skills and solve issues that arose after returning to the community, 30 (86%) studies used home visits, telephone follow-ups, or both, with a wide variation in their use. Ohuabunwa and colleagues (2013) made follow-up phone calls at 2, 7, and 14 days after discharge and added a home visit for participants who had limited social support. Kwok et al. (2008) used a home visit, which occurred within 7 days of discharge, followed by weekly visits for the first month and monthly visits for the first 6 mo after discharge. Three studies also provided participants with a hotline to call for questions (Casas et al., 2006; Kwok et al., 2008; Naylor et al., 2004). The follow-up encounters served as a safety net for the patient and caregiver to support further development of health management and advocacy skills as well as to address emerging medical and psychosocial issues.
Discussion
In the context of value-based payment, PAC providers will be challenged to reframe the discharge process and think more broadly about facilitating a successful community discharge. The findings of this study emphasize the importance of equipping patients and their caregivers with the knowledge and tools to effectively transition to the community and manage their ongoing medical and functional needs within their own context and environment. Given the paucity of PAC-specific care transition evidence, this review can provide guidance to researchers and health systems as they consider translating, implementing, and evaluating existing care transition programs, such as the ones highlighted in this review to meet the needs of a PAC patient population.
Toward this end, research describing the unmet transition needs of PAC rehabilitation patients and caregivers has highlighted the absence of long-term medical management skills, concerns about adverse events (e.g., accidental falls), limited understanding of the recovery process, uncertainty in how to navigate the health care system and the care transition, and feeling excluded from care decisions (Brereton & Nolan, 2000; Davey et al., 2004; Ellis-Hill et al., 2009; Mackenzie et al., 2007). Future PAC transition initiatives should therefore address these unmet needs to optimize the patient’s return to the community. More specifically, the care processes highlighted in this review can inform such efforts and serve as a foundation for translating effective interventions to PAC.
For example, this review found that education, training, and teach-back sessions are effective in preparing the patients (and caregivers) for the care transition. These sessions addressed a variety of topics, such as health management approaches, medication management strategies, tactics for communicating with health care providers, and an overview of what to expect during the care transition (Jack et al., 2009; Koehler et al., 2009; Naylor et al., 2004; Sethares & Elliott, 2004). Efforts such as care transition coaching, which provide the patient and caregiver with information about what to expect when returning to the community, have effectively reduced readmissions by 14% (Jones et al., 2016) and was used in 14 of the 18 effective interventions in this scoping review. Caution is warranted when translating these processes to PAC. The relationships among the care processes, the needs of the caregiver and patient, and readmissions will have to be empirically evaluated in a PAC context.
Moreover, when translating initiatives from other settings to PAC, care transition initiatives should consider the frequency and duration of the intervention. This scoping review found that providing multiple care transition sessions throughout the care stay and offering access to supports after discharge reinforced knowledge and strengthened skill building as well as enhanced patient and caregiver confidence (Berkowitz et al., 2013; Courtney et al., 2009; Huntington et al., 2013; Sethares & Elliott, 2004).
Finally, future research should examine the contribution of each member of the interdisciplinary team in facilitating effective PAC care transitions. To begin to address this issue, Rogers and colleagues (2017) found a significant relationship between the delivery of occupational therapy services and a lower likelihood of readmissions; yet, because of data limitations, the authors were unable to isolate the discrete processes delivered by the occupational therapists that resulted in the study findings. Thus, in response to this gap in PAC evidence, and given the high risk of falls in this PAC population and caregivers’ concerns about preventing this adverse event, accidental falls may be a treatment domain to include in care transition interventions. Toward this end, home safety assessments before discharge have decreased the occurrence of falls resulting in readmissions after discharge (Johnston et al., 2010). Similarly, Roberts and Robinson (2014) postulated that evaluating the patients’ (and caregivers’) abilities and integrating their beliefs, values, context, and environment are essential for developing a patient-centered community care transition intervention and should also be considered when developing a comprehensive interdisciplinary intervention. Nonetheless, future studies in PAC will be required to empirically determine the role of each provider and his or her contribution toward preventing readmissions and fostering successful community care transitions.
Although this study has addressed a knowledge gap in the PAC community care transition literature and proposes direction for future research and practice, it does have limitations. Because of the limited number of intervention studies that have examined PAC in addressing readmissions, we chose to conduct a scoping review to summarize existing community care transition approaches, which could inform future PAC research and practice. Because a systematic review was not done, the strength and quality of the included studies were not evaluated, and we cannot ensure that all relevant evidence was identified by our search strategies. We included both U.S. and international studies, but caution is needed when considering the translation of interventions executed in other countries because they may not translate to the U.S. health care system. In addition, although research in primary care was excluded from this study, future research evaluating PAC community transition care processes may gain valuable information from the primary care literature that targets chronic disease management. Despite these limitations, this study provides some areas for investigation that can serve as a starting point for future PAC community transition research.
Implications for Occupational Therapy Practice
Rehabilitation patients and caregivers have expressed concerns about being ill equipped for the community transition. Although none of the interventions in this scoping review included occupational therapy practitioners as part of the acute care team, translating this acute care evidence to PAC would necessitate prioritizing these expressed needs of the rehabilitation patient and caregiver. In response, occupational therapy practitioners are well situated to be an active member of the care team, given their ability to examine the interplay among the person, the environment, and desired occupations. By capitalizing on this perspective and working collaboratively with the patient, caregivers, and interdisciplinary team to address medical, functional, and psychosocial needs during the care transition, occupational therapy practitioners can assist in the prevention of readmissions after PAC discharge.
Toward this end, the profession and its practitioners need to increase awareness of occupational therapy’s value when addressing readmissions, such as through research that evaluates the relationship between occupational therapy care processes and readmission outcomes, clinical quality improvement initiatives, and professional advocacy. To be specific, this line of inquiry is well situated to capitalize on research–practitioner collaborations to design patient-centered interventions that can be immediately implemented into practices. In the list that follows, I propose opportunities for occupational therapy that need to be evaluated in the context of community care transitions:
Assess the patients’ (and caregivers’) occupational performance, integrating their beliefs, values, and context and environment to guide the focus of the care transition intervention and provide them with the necessary skills and knowledge to limit the risk of readmissions.
Address effective health management approaches, medication management strategies, what to expect during the care transition, and tips for communicating patients’ needs to health care providers by integrating education, training, and teach-back sessions during occupational therapy sessions throughout the acute and PAC stay.
Augment the interdisciplinary team’s medical management education efforts by reinforcing information within an appropriate context of health literacy and application to the caregivers’ and patients’ everyday lives. This goal can be achieved by approaching the issues from an occupational performance perspective and drawing on the patients’ and caregivers’ habits, roles, and routines to optimize health management, home safety, and medication management strategies (Saleh et al., 2012).
Occupational therapists are trained to assess functional needs in the context of a variety of medical conditions and impairments, which can inform decisions regarding whether patients can return home safely. Toward this end, it is important to identify new and existing disabilities that limit a patient’s ability to perform basic activities of daily living (e.g., feeding self, going to the bathroom, getting dressed). Attention to these functional needs and the patient’s ability to safely perform activities of daily living after discharge are a key role for occupational therapists.
Guided by the occupational, psychosocial, and medical needs of the patient and caregiver, the occupational therapy practitioner can help connect them with community resources to support their health and well-being after discharge.
Conclusion
In the context of required reporting of readmissions in PAC, there is an urgent need to evaluate these community care transition processes in the context of PAC. Although this review found that there are effective multicomponent interventions in acute care, the extent to which these care processes within the broader interventions translate to a PAC setting and meet the needs of rehabilitation patients and caregivers should be evaluated. In addition, the contribution of occupational therapy intervention to this key outcome needs to be assessed. The care processes identified in this scoping review can serve as a foundation for developing and evaluating PAC community transition interventions.
Supplemental Material
Supplementary material for Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review
Supplementary material, sj-pdf-1-aot-10.5014_ajot.2019.005157.pdf for Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review by Natalie E. Leland, Pamela Roberts, Roxanne De Souza, Sun Hwa Chang, Kruti Shah and Marla Robinson in The American Journal of Occupational Therapy
Footnotes
Acknowledgments
Natalie E. Leland was funded by the National Center for Medical Rehabilitation Research (Eunice Kennedy Shriver National Institute of Child Health and Human Development) and the National Institute of Neurological Disorders and Stroke (K12 HD055929; principal investigator, Kenneth Ottenbacher).
*Indicates article included in the scoping review.
References
Supplementary Material
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