Over a 12-month period (January 2019 to December 2019), 107 patients were enrolled into the program. Of the 107 patients who consented, 23 patients terminated their enrollment early (before 3-month end date). The main reasons for termination included inconsistent home presence (16), issues with the food (5), and self-termination for undisclosed reasons (2). Therefore, the evaluation of the pilot study moving forward includes our 84 patients who completed the study.
Baseline Characteristics
The mean age of the participants was 74.9 ± 10.5 (range 60 to 93) years with 33 (39.3%) being female. The mean body mass index of the patients was 27.0 ± 6.3. In regard to socioeconomic status, the majority of patients resided in disadvantaged neighborhoods, as identified by the area deprivation index, with a mean 78.2 ± 17.2 (range 52 to 99). A complete listing of the cohort’s sociodemographic variables can be found in Table 1.
Table 1
Characteristics of participants.
Variable
|
Patient Population
N=84
|
Age (years)
|
74.9 ± 10.5
|
Females (%)
|
33 (39.3)
|
Body Mass Index
|
27.0 ± 6.3
|
Race
White (%)
African American (%)
|
65 (77.4)
19 (22.6)
|
Hispanic/Latino (%)
|
1 (1.2)
|
Lives with Family (%)
|
62 (73.8)
|
ADI
Residing in ADI ≥85 (%)
|
78.2 ± 17.2
62 (73.8%)
|
Sequential Organ Failure Score (at hospital admission)
|
3.2 ± 1.1
|
Charlson Co-morbidity Index
|
7.6 ± 2.5
|
Co-Morbidities (%)
COPD
Heart Failure
Hypertension
Diabetes
|
54 (64.3)
35 (41.7)
72 (85.7)
68 (81.0)
|
Number of Medications
|
15.1 ± 6.6
|
Length of Hospitalization (days)
|
6.5 ± 4.6
|
Intensive Care Unit Admission (%)
|
41 (48.1)
|
Designated Home Health Care at time of Hospital Discharge
Nurse (%)
PT/OT (%)
Physician (%)
|
22 (26.2)
10 (8.4)
1 (1.2)
|
COPD = Chronic Obstructive Pulmonary Disease; PT/OT = Physical Therapy and Occupational Therapy; ADI = Area Deprivation Index |
In regard to the cohort’s hospitalization that resulted in enrollment into the trial, the mean length of hospitalization was 6.5 ± 4.6 days (range 1 day to 13 days) where 41 (48.1%) participants had an intensive care unit admission as well. Of note, 80 (95.2%) of the participants had an intensive care unit admission within the past 12 months. The Charlson Co-Morbidity Index of the cohort was 6.6 ± 2.5 (range 3 to 11), whereby the median 10-year survival of the cohort was 2% (IQR 0%, 21%)15. The most common co-morbidity amongst the cohort was hypertension, with 72 (85.7%). Finally, the mean number of medications for the cohort upon returning home from the hospital was 15.1 ± 6.6 (range 5 to 25). Table 1 further summarizes other medical information of the cohort.
Feasibility and Process Outcomes
Each participant in the transition team received home inspections, food deliveries, and daily surveys. Through the surveys, and in discussions with our care manager, several issues were identified that were not reported in hospital in-patient notes and discharge paperwork. Illiteracy was identified in two patients, while overall health literacy6,17,18 concerns were identified in all of the participants. Through the surveys, several key issues were identified by the participants, ranging from an ongoing desire to be independent, to a general anxiety over attending physician clinical visits, to feeling that health issues are not a priority compared to managing economic issues (e.g., employment, housing affordability). Table 2 summarizes key themes that were identified by our transition team that were felt to impact the overall management of the participant’s co-morbidities, with various example summaries from the surveys. Note these responses were grouped into six themes: “Insight into Health Condition”, “Trust of the Medical System”, “Access to Health Care Equipment”, “Competing Priorities”, “Caregiver Concerns”, and “Communication Access”. Medical supplies (e.g., blood pressure cuffs, scales) were purchased for 14 participants through MOWCM. Of note, no home falls were reported by the patients after their home renovations were completed.
Table 2
Key concerns identified during the transition initiative.
Theme
|
|
Insight into Health Condition
|
“Client wants to be very independent, wants to eat any food, and wants to walk wherever despite his losing balance and falling frequently.”
|
Trust of the Medical System
|
“Client states ‘hates going to doctors’ and often times refuses to go to clinic as the client feels ‘they don’t understand me’.”
|
Access to Health Care Equipment
|
“Client states she cannot read or write. Unstable living situation and no access to a walker (recommended).”
|
Competing Priorities
|
“Client states she cannot afford meds and groceries. Her husband does not work and has no form of income.”
|
Caregiver Concerns
|
“Caregiver/daughter feels unable to leave her mother's side and can't take a break or leave the house. Client has dementia and is at risk of falling. Client's daughter can't afford respite care.”
|
Communication Access
|
“Client shares phone with husband, who is usually out of the house. Communication with the client is difficult.”
|
Readmission Outcomes
Twenty-seven (32.1%) patients were readmitted within 30-days (Figure 1). Of those 27, only one was readmitted to an intensive care unit. The majority of the participants’ (20 of the 27) readmissions occurred within the first 15 days after returning from the hospital. Over the 3-month period, 37 total patients were readmitted to the hospital, and this cohort of 37 participants had an additional 122 emergency room visits during the 3-month span that did not result in hospitalization, resulting in 159 total hospital visits. In comparison to the 3-months prior enrollment of the complete cohort, there were 181 hospital visits: 142 admissions and 41 emergency room visits that did not result in hospitalizations. Comparing hospitalizations before and after enrollment over 3-months, there was a significant reduction in hospital admissions (142 before enrollment versus 37 after enrollment, p<0.001), while there was an increase in emergency room visits that did not result in admissions (41 emergency room visits versus 122 emergency room visits, p<0.001). Ten patients had passed away within 3 months of enrolling into the program.
Of the 84 participants enrolled, 49 have been followed for a complete 12-months and had their respective cost-savings in regards to hospitalizations after enrollment in Together In Care analyzed. At the 3-month mark of enrollment, of the 49 participants, 48 were hospitalized with total hospital expenditures being $435,258 ± 113,423 as compared to $1,445,637 ± 325,433 (p<0.01) of their cost during the 3-months prior to enrollment (Figure 2). At the 6-month mark of enrollment, of the 49 participants, 42 experienced hospitalizations between months 3 to 6, with total hospital expenditures (all 6-months) being $899,106 ± 243,987 as compared to $1,853,406 ± 477,586 (p<0.01) of their cost during the 6 months prior to enrollment. At the 12-month mark of enrollment, of the 49 participants, 17 experience hospitalizations between months 6 to 12, with total hospital expenditures (all 12-months) being $901,382 ± 375,588 as compared to $1,575,947 ± 273,444 (p=0.04) of their cost during the 12 months prior to enrollment (Figure 2).