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Association of Timely Outpatient Follow-Up and Readmission Risk in a Mobile Integrated Health Program.

Nicholas Brady1, Yuanyuan Liang2, Kristin L Seidl3,4

  • 1University of Maryland School of Medicine, Baltimore, Maryland, USA.

Population Health Management
|April 29, 2024
PubMed
Summary

Timely outpatient follow-up reduced 30-day readmissions for younger patients and those with fewer social needs. Mobile integrated health-community paramedicine (MIH-CP) programs can target these groups for better outcomes.

Keywords:
health services researchpolicy evaluationprimary carequality improvementutilization

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Area of Science:

  • Health Services Research
  • Public Health
  • Emergency Medicine

Background:

  • Hospital readmissions pose a significant burden on healthcare systems.
  • Mobile integrated health-community paramedicine (MIH-CP) programs offer innovative solutions for post-discharge care.
  • Understanding factors influencing readmission risk is crucial for optimizing patient outcomes.

Purpose of the Study:

  • To identify medical conditions linked to 30-day readmissions.
  • To determine patient characteristics benefiting most from outpatient follow-up to reduce readmissions.
  • To evaluate the impact of timing of outpatient follow-up within an MIH-CP program on readmission risk.

Main Methods:

  • Retrospective observational study of 1,118 adult MIH-CP program enrollments.
  • Bivariate analysis to identify readmission risk factors.
  • Kaplan-Meier curves and Cox regression to analyze readmission hazard with follow-up timing.
  • Receiver operating characteristic analysis to assess predictive value of follow-up time.

Main Results:

  • No specific chronic disease exacerbations were significantly associated with higher readmission risk.
  • Timely outpatient follow-up significantly reduced readmission risk for patients aged 50 and younger.
  • Patients with fewer than 5 identified social determinants of health needs showed reduced readmission with timely follow-up.
  • An optimal follow-up time frame for readmission reduction could not be identified.

Conclusions:

  • Timely outpatient follow-up is effective in reducing 30-day readmissions for younger patients and those with lower social complexity.
  • MIH-CP programs may enhance effectiveness by focusing on these patient subgroups.
  • Targeted interventions within MIH-CP programs can improve healthcare resource utilization and patient care.