Improving Telehealth Transition of Care Programs Focused on Readmission Reduction

Area of Science:

• Healthcare Management
• Patient Care
• Telehealth

Background:

• Suboptimal hospital-to-home transitions lead to adverse health outcomes and increased costs.
• Telehealth transitional care programs show promise in reducing readmissions, but patient benefit variability requires investigation.
• A connected transitional care (CTC) program using nurse practitioner-led telehealth appointments for high-risk patients was evaluated.

Purpose of the Study:

• To understand why some patients benefit from a telehealth transitional care program and avoid readmission, while others do not.
• To identify factors associated with successful outcomes in a connected transitional care program.

Main Methods:

• Analysis of readmission rates comparing patients who engaged in telehealth visits versus those who did not.
• Qualitative chart review of engaged patients who were readmitted versus those who were not readmitted.

Main Results:

• 32.2% of referred patients engaged with the program.
• Engaged patients had a 12% relative risk reduction in readmissions (18.7% vs. 21.3%).
• Non-readmitted patients had earlier follow-up, greater caregiver involvement, addressed social needs, less need for interpretation, and better mental status.

Conclusions:

• Telehealth transitional care may reduce readmissions, warranting further statistical analysis.
• Qualitative findings highlight the importance of family engagement, social support, and behavioral health interventions.
• Improvements in the connected transitional care program could enhance patient outcomes and reduce readmissions.