An Emergency Department-to-Home Intervention to Improve Quality of - - PowerPoint PPT Presentation

An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use

Patient-Centered Outcomes Research Institute Improving Healthcare Delivery Systems

Jeffrey Harman, PhD Jessica Schumacher, PhD Allyson Hall, PhD Phyllis Hendry, MD Barbara Lutz, RN, PhD Jingnan Zhang, PhD Jonathan Shuster, PhD Donna L. Carden, MD

Research reported in this presentation was funded through the Patient-Centered Outcomes Research Institute (PCORI) Award IHS-1306-01451

Background

• Improved care transitions,

particularly for older, chronically ill Americans is a national priority

• Many of the biggest drivers of

health and health care costs are beyond the scope of health care alone

• Rigorous research is needed to

assess a causal link between care transition interventions and outcomes important to key ED stakeholders including ED patients

Patient

Healthcare System Health- related Social Needs Care Coordination Community

Care Transition Interventions Implemented in Admitted Patients Reduce Hospital Readmissions

% Hospital Readmissions CTI= Care Transition Intervention Implemented by local Area Agency on Aging Before CTI After CTI 24.1% 12.7%

Background

Rand Corporation 2013: The Evolving Role of Emergency Departments in the United States.

Background

Most Medicare Beneficiaries Enter Through the ED

PCORI Project Team

Compared to usual, post-ED care, can an intervention that links chronically ill, older patients with community-based medical and social support improve quality of life and reduce hospital-based healthcare use?

2013 Planning Meeting 2015 Team Meeting

Outcome Measures Aim 1: Quality of Life and Health Service Use- Survey, EHR, Medicare Claims Aim 2: In-depth Interviews with patients in their homes, coaches, and providers Baseline ED Survey (Quality of Life-PROMIS) Home Visit 3 Telephone Calls Follow up Telephone Survey (Quality of Life- PROMIS)

2 Area Agencies on Aging

• Doctor Office Visit
• Disease Red Flags
• Medication
• Personal Health Record
• Nutrition
• Transportation

Usual Care 500 Intervention 504

Methods

73% 76%

Patient Characteristics

10 20 30 40 50 60 70 80 90 100 Percent Intervention Usual Care

Between-Group Differences*

Assignment Follow-Up Survey Medicaid + + Older Age

• Female

+ Lower Education

• Limited Health Literacy
• More Chronic Conditions
• Worse Physical Status at

Baseline

• Worse Informational Support at

Baseline +

* p<0.05

Analysis

• Account for patient characteristic differences between groups

and non-response with propensity score weighting approach

– Allows more weight to be given to patients most like those who did not respond and are under-represented in the sample

• Difference-in-Difference Approach

– Compare differences in quality of life scores between the Intervention and Usual Care groups at follow-up and baseline

[Follow-Up (Intervention-Usual Care)] – [Baseline (Intervention-Usual Care)]

– Stratified by site (Jacksonville and Gainesville) and number and type of chronic condition – Intention to treat approach

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual care Average Info Support Score Difference Follow-up-Baseline

Informational Support

Overall

No significant informational support differences for patients in Intervention compared to Usual Care

DID = -2.05, p=0.88

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual care

Average Info Support Score Difference Follow-up-Baseline

0 to 2 3 to 4 5 or more

Informational Support

Number of Comorbidities

Larger informational support decline in the Usual Care compared to the Intervention group for those with 3-4 conditions

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual Care Average Emotional Distress/Anxiety Score Difference Follow-up-Baseline

Emotional Distress / Anxiety

Overall

Significantly greater increase in anxiety in Intervention compared to Usual Care group

DID = 1.26, p=0.028

Physical Function

• Overall and when assessed by number of

chronic medical conditions, there were no significant differences in physical functioning scores between the Intervention and Usual Care groups

Conclusions

• Patient‐reported quality of life in all reported domains is highest at

the time of the ED visit and falls in the days following the encounter

– This suggests patients will likely continue to have ED visits to resolve healthcare crises – Confirmed and extended in in-depth interviews

• Although the intervention did not result in short term

improvements in physical health status or anxiety, the intervention significantly attenuated declines in self‐reported informational support

– An ED‐to‐Home Intervention may have longer term impacts on patients’ ability to obtain, process, and use health information and more efficiently use healthcare services

Policy Implications:

Improving Healthcare Delivery System

• The ED as a site to deploy Care Transition Interventions has

been under-recognized and under-utilized

– Perhaps the focus should shift from curbing ED visits to leveraging them to be more helpful for patients

The opinions in this presentation are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.

Future Work

• Analyses will focus on the intervention’s

impact on subsequent ED and inpatient utilization, interpreted in the context of patient well-being and measures of patient complexity

Acknowledgements

• Jan Rosini
• Dawn Rosini
• Yvonne Davis
• Ron Morris
• Dolly Horlacher
• Veronica Matthews
• Sharon Fort
• Linda Levine
• Kristen Griffis
• Katina Mustipher
• Renee Knight
• Jennifer Reynolds
• Colleen Kalynych
• Rebecca Murray
• Kristy Radeker
• Meena Balakrishnan

Informational Support

Diabetes

Larger info support decline for patients with diabetes in usual care versus intervention

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual care

Average Info Support Score Difference Follow-up-Baseline DID = -2.59, p=0.039

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual care

Average Info Support Score Difference Follow-up-Baseline

Informational Support

COPD

Larger info support decline for patients with COPD, in usual care group versus intervention

DID = -3.41, p<0.001

Informational Support

Hypertension

Larger info support decline for patients with hypertension in usual care vs intervention

• 5
• 4
• 3
• 2
• 1

1 2 Intervention Usual care

Average Info Support Score Difference Follow-up-Baseline DID = -1.68, p=0.044