Using hospital use trends to improve transitional care.

Area of Science:

• Health Services Research
• Healthcare Management
• Public Health

Background:

• Evaluates the Northwestern Medicine Group Transitional Care clinic (NMG-TC) model.
• Focuses on patient transitions from urban hospitals to community primary care.
• Assesses changes in hospital use within 90 days of NMG-TC visits over 55 months.

Purpose of the Study:

• To evaluate the impact of the NMG-TC program on post-discharge hospital utilization.
• To identify factors influencing hospital use after transitional care.
• To assess changes in hospital use trends over a 55-month study period.

Main Methods:

• Utilized electronic health records for a cohort of 3318 patients.
• Analyzed demographic, insurance, and clinical characteristics, including pre- and post-visit hospital charges.
• Employed multiple logistic regression to determine the likelihood of 90-day hospital use, controlling for patient and pre-visit factors.

Main Results:

• 28.5% of patients experienced 90-day post-visit hospital encounters.
• Cancer, infectious disease, and pain diagnoses were associated with higher hospital use.
• Later NMG-TC visits (2015-2016) showed a 38% lower likelihood of 90-day hospital use compared to earlier visits (2011-2012).

Conclusions:

• Reduced post-visit hospital use is likely attributable to enhanced clinic resources.
• Affordable Care Act insurance expansions may have contributed to decreased hospital utilization.
• Improved expertise in clinical and community social services likely plays a role in better patient outcomes.