Analysis of Readmissions in a Mobile Integrated Health Transitional Care Program Using Root Cause Analysis and Common...

Area of Science:

• Public Health
• Healthcare Management
• Emergency Medical Services

Background:

• Mobile Integrated Health and Community Paramedicine (MIH-CP) programs aim to improve healthcare access.
• Understanding patient readmission factors is crucial for program development and quality improvement.
• Baltimore City's MIH-CP program sought to analyze readmission circumstances after one year of operation.

Purpose of the Study:

• To identify factors contributing to patient readmissions within an MIH-CP program.
• To differentiate between preventable and unpreventable readmissions.
• To hypothesize the role of social determinants of health (SDOH) in preventable readmissions.

Main Methods:

• Retrospective chart review of patients enrolled in the Baltimore City MIH-CP program.
• Analysis of root causes for readmissions, focusing on SDOH.
• Application of Common Cause Analysis to identify areas for program improvement.

Main Results:

• Social determinants of health were identified as root causes in 75.8% of preventable readmissions, compared to 15.2% of unpreventable readmissions.
• Key factors influencing preventable readmissions included health literacy, functional status, and behavioral health.
• Common Cause Analysis indicated a need to focus MIH-CP resources on mitigating poor health literacy and functional status.

Conclusions:

• Deficits in social determinants of health are strongly linked to preventable readmissions in MIH-CP programs.
• The findings guided modifications to Baltimore City's MIH-CP program processes.
• Quality improvement tools, including root cause and common cause analysis, are valuable for directing MIH-CP program development.