Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization
Background: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation. Methods: 1,16...
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| Format: | Article |
| Language: | English |
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Ubiquity Press
2017-08-01
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| Series: | International Journal of Integrated Care |
| Subjects: | |
| Online Access: | https://www.ijic.org/articles/3050 |
| _version_ | 1819156637128065024 |
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| author | Lian Leng Low Wei Yi Tay Shu Yun Tan Elian Hui Shan Chia Rachel Marie Towle Kheng Hock Lee |
| author_facet | Lian Leng Low Wei Yi Tay Shu Yun Tan Elian Hui Shan Chia Rachel Marie Towle Kheng Hock Lee |
| author_sort | Lian Leng Low |
| collection | DOAJ |
| description | Background: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation. Methods: 1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge. Results: We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders. Conclusion: Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions. |
| first_indexed | 2024-12-22T15:56:02Z |
| format | Article |
| id | doaj.art-f58c12c07af94b93b20f9013c96724b4 |
| institution | Directory Open Access Journal |
| issn | 1568-4156 |
| language | English |
| last_indexed | 2024-12-22T15:56:02Z |
| publishDate | 2017-08-01 |
| publisher | Ubiquity Press |
| record_format | Article |
| series | International Journal of Integrated Care |
| spelling | doaj.art-f58c12c07af94b93b20f9013c96724b42022-12-21T18:20:47ZengUbiquity PressInternational Journal of Integrated Care1568-41562017-08-0117410.5334/ijic.30502825Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilizationLian Leng Low0Wei Yi Tay1Shu Yun Tan2Elian Hui Shan Chia3Rachel Marie Towle4Kheng Hock Lee5Department of Family Medicine and Continuing Care, Singapore General Hospital; and Family Medicine, Duke-NUS Medical SchoolDepartment of Family Medicine and Continuing Care, Singapore General Hospital; and Family Medicine, Duke-NUS Medical SchoolDepartment of Family Medicine and Continuing Care, Singapore General Hospital; and Family Medicine, Duke-NUS Medical SchoolHealth Services Research and Evaluation, Singapore Health Services Regional health System OfficeDepartment of Family Medicine and Continuing Care, Singapore General HospitalDepartment of Family Medicine and Continuing Care, Singapore General Hospital; and Family Medicine, Duke-NUS Medical SchoolBackground: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation. Methods: 1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge. Results: We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders. Conclusion: Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions.https://www.ijic.org/articles/3050Home caretransitional careintegrated careintegrated practice unitreadmissions |
| spellingShingle | Lian Leng Low Wei Yi Tay Shu Yun Tan Elian Hui Shan Chia Rachel Marie Towle Kheng Hock Lee Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization International Journal of Integrated Care Home care transitional care integrated care integrated practice unit readmissions |
| title | Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization |
| title_full | Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization |
| title_fullStr | Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization |
| title_full_unstemmed | Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization |
| title_short | Transitional Home Care program utilizing the Integrated Practice Unit concept (THC-IPU): Effectiveness in improving acute hospital utilization |
| title_sort | transitional home care program utilizing the integrated practice unit concept thc ipu effectiveness in improving acute hospital utilization |
| topic | Home care transitional care integrated care integrated practice unit readmissions |
| url | https://www.ijic.org/articles/3050 |
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