ABSTRACT Background: “Seamless care” is a smooth and safe transition of a patient from the hospital to the home. Our goal was to identify ways to maximize improvement in postdischarge patient outcomes. This research targeted patients at risk for unscheduled readmissions, examined delivery system processes, and identified possible interventions for providing more seamless care. Methods: This pilot study included three phases. In the first phase, we examined selected readmissions using extant administrative databases for fiscal year 2001 at two facilities, a Department of Veterans Affairs (VA) hospital and a private, nonprofit hospital. We identified patient characteristics that were associated with a high risk of unscheduled readmission within 30 days of discharge for three Diagnosis Related Groups (DRGs) (127-Heart Failure, 89-Pneumonia (> 17 years), and 109-Coronary Artery Bypass Graft without catheterization). Survival analyses and other statistical techniques were used. An expert panel focus group provided insights into discharge planning processes. Finally, patients in these DRGs at the two hospitals who were discharged and had an unscheduled readmission within 30 days were interviewed to obtain their perceptions of factors that might have contributed to their readmissions. Results: Factors associated with readmissions varied by DRG. Numbers of secondary diagnoses, length of stay, and Clinical Classification Software (CCS) category were the most consistent predictors of readmission. Age, gender, and race were not predictive. Qualitative analysis identified several themes that centered on communication issues between patients and providers, providers and caregivers, and between different providers. Patients' perceptions of what might have prevented readmission included longer hospital stay to ensure stabilization, enhanced patient education and involvement in the decisionmaking process, increased assurance of medication/treatment effectiveness prior to discharge, home health nursing, increased staffing, and timeliness of followup appointments. Conclusions: Despite very different organizational structures and processes, we found similar patient populations, risk factors, and outcomes in the two hospitals. The linkages in these different health care facilities between readmissions and health system barriers to safe and smooth transitional care confirm findings in other studies. Patient and organizational factors each contributed to unscheduled readmissions. High-risk patient targeting, improved communications (including a greater emphasis on language barriers and cultural differences), and better coordination of care and followup could potentially prevent some readmissions when transitioning patients from the hospital to the home.
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