Telehealth-based transitional care management programme to improve access to care

Area of Science:

• Healthcare Management
• Nursing Practice
• Health Services Research

Background:

• The transition from hospital to home presents a vulnerable period for patients and families.
• Effective care coordination and structured discharge planning are crucial for improving patient outcomes.
• High 30-day hospital readmission rates indicate a need for enhanced post-discharge support.

Purpose of the Study:

• To assess the impact of a telehealth outreach program by a registered nurse (RN) on 30-day hospital readmission rates.
• To evaluate the program's effectiveness in both overall and disease-specific patient populations.
• To improve patient engagement and access to services after acute care discharge.

Main Methods:

• Prospective observational study conducted from May 2021 to December 2022.
• Telehealth outreach by an RN within 72 hours of discharge to assess discharge instructions, medication access, follow-up appointments, and social needs.
• Analysis of overall and disease-specific (CHF, COPD, PNA) readmission rates compared to a 40-month prestudy cohort.

Main Results:

• Median readmission rates decreased by 1.2% (11.0% to 9.8%) compared to the prestudy cohort.
• Significant reductions in readmissions were observed for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia (PNA).
• Patients contacted within 24-48 hours post-discharge were 1.2 times less likely to be readmitted.

Conclusions:

• A multifaceted telehealth approach enhances patient engagement and access to care.
• This intervention effectively reduces 30-day hospital readmissions for patients discharged from acute care settings.
• Telehealth outreach by RNs is a valuable strategy for improving post-discharge care coordination and patient outcomes.