An Interdisciplinary Videoconference to Improve Transitions of Care and Reduce Readmission, Cost, and Post-Acute Length of Stay in a Teaching and Community Hospital

Abstract

Objectives: Coordination of care across health care settings is needed to ensure safe patient transfers. We examined the effects of the ECHO-Care Transitions program (ECHO-CT) on readmissions, skilled nursing facility (SNF) length of stay (LOS), and costs.

Design: This is a prospective cohort study evaluating the ECHO-CT program. The intervention consisted of weekly 90-minute teleconferences between hospital and SNF-based teams to discuss the care of recently discharged patients.

Setting and participants: The intervention occurred at one small community hospital and 7 affiliated SNFs and 1 large teaching hospital and 11 associated SNFs between March 23, 2019, and February 25, 2021. A total of 882 patients received the intervention.

Methods: We selected 13 hospitals and 172 SNFs as controls. Specific hospital-SNF pairings within the intervention and control groups are referred to as hospital-SNF dyads. Using Medicare claims data for more than 10,000 patients with transfers between these hospital-SNF dyads, we performed multivariable regression to evaluate differences in 30-day rehospitalization rates, SNF lengths of stay, and SNF costs between patients discharged to intervention and control hospital-SNF dyads. We split the post period into pre-COVID and COVID periods and ran models separately for the small community and large teaching hospitals.

Results: There was no significant difference-in-differences among intervention compared to control facilities during either post-acute care period for any of the outcomes.

Conclusions and implications: Although video-communication of care plans between hospitalists and post-acute care clinicians makes good clinical sense, our analysis was unable to detect significant reductions in rehospitalizations, SNF lengths of stay, or SNF Medicare costs. Disruption of the usual processes of care by the COVID pandemic may have played a role in the null findings.

Keywords: Care transitions; quality improvement; rehospitalization.