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

Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.