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Evaluating a Mobile Integrated Health Transitional Care Program to Reduce Readmissions: Findings From a

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Paramedic-led mobile integrated health (MIH) programs, like the PACED intervention, significantly reduce 30-day rehospitalization for older adults post-discharge. This approach supports aging in place and improves transitional care outcomes.

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Area of Science:

  • Gerontology
  • Health Services Research
  • Mobile Integrated Health

Background:

  • Hospital discharge is a vulnerable period for older adults, increasing risks of medical, functional, and social decline.
  • Mobile Integrated Health (MIH) programs offer potential solutions for transitional care gaps.
  • The effectiveness of MIH in post-discharge care for frail older adults requires further evaluation.

Purpose of the Study:

  • To assess the impact of the Paramedic Assisted Community Evaluation (after) Discharge (PACED) intervention on 30-day rehospitalization rates.
  • To evaluate the association between the PACED intervention and 30-day emergency department (ED) utilization.
  • To investigate the role of MIH in supporting frail older adults during the post-hospitalization transition.

Main Methods:

  • A prospective observational study design was employed.
  • Older adults discharged from an urban academic medical center were offered a paramedic-delivered home visit within 72 hours (PACED intervention).
  • A comparator group was established using patients who lived outside the program's area, lacked a system-affiliated PCP, or declined the visit; modified Poisson regressions analyzed outcomes.

Main Results:

  • The PACED intervention group (n=190) showed significantly lower 30-day rehospitalization rates (12.6%) compared to the comparator group (n=107, 21.5%).
  • Adjusted relative risk for rehospitalization was 0.45 (95% CI: 0.26-0.77, p=0.003) for PACED participants.
  • PACED participants also experienced fewer 30-day ED visits (11.5% vs. 18.7%, adjusted RR 0.58, p=0.05).

Conclusions:

  • In-home MIH transitional care programs like PACED are associated with reduced 30-day readmission rates for frail older adults.
  • These findings suggest MIH is a valuable model for supporting aging in place.
  • MIH interventions demonstrate potential for integration into age-friendly health systems.