Background: Optimal transition care represents an important step in mitigating the risk of early hospital readmission. For many hospitals, however, resources are not available to support transition care processes, and hospitals may not be able to identify patients in greatest need. It remains unknown whether a coordinated quality improvement campaign could help to increase a) identification of at-risk patients and b) use of a readmission risk score to identify patients needing extra services/resources.
Methods: The American College of Cardiology Patient Navigator Program was designed as a 2-year (2015-2017) quality improvement campaign to assess the impact of transition-care interventions on transition care performance metrics for patients with acute myocardial infarction (AMI) and heart failure (HF) at 35 acute care hospitals. All sites were active participants in the NCDR ACTION Registry. Facilities were free to choose their transition care priorities, with at least 3 goals established at baseline. Pre-discharge identification of AMI and HF patients and assessment of their respective readmission risk were 4 of the 36 metrics tracked quarterly. Performance reports were provided regularly to the individual institutions. Sharing of best practices was actively encouraged through webinars, a listserv, and an online dashboard with display of blinded performance for all 35 hospitals.
Results: At baseline, 31% (11/35) and 23% (8/35) of facilities did not have a process for prospectively identifying AMI and HF patients, respectively. At 2 years, the rate of not having processes decreased to 8% (3/35) and 3% (1/35), respectively. Among hospitals able to identify AMI and HF patients, there was high patient-level identification performance from the outset (91% for AMI and 86% for HF at baseline), with added improvement over 2 years (+2.2% for AMI and +9.3% for HF). At baseline, processes to assess readmission risk for AMI and HF patients were only completed by 26% (9/35) and 31% (11/35) of facilities, respectively. At 2 years, AMI and HF readmission risk assessment rose to 80% (28/35) and 86% (30/35), respectively. Similar improvements were noted at the patient-level, with 34% (52% --> 86%) and 16% (75% --> 91%) absolute 2-year increases in the percentage of AMI and HF patients undergoing assessment of readmission risk, respectively.
Conclusions: Implementation of a quality improvement campaign focused on care transition can substantially improve prospective identification of AMI and HF patients and assessment of their readmission risk. It remains to be determined whether process improvement lead to reduction in 30-day readmission and/or improvement in other clinically important outcome measures.