21 July 2023

Unnecessary hospitals re-admission rates for at-risk patients could be slashed by more than half if hospitals help patients co-ordinate their healthcare needs within their community, according to new research from the Royal Australasian College of Physicians’ (RACP) Internal Medicine Journal.

The study, in July’s RACP Internal Medicine Journal published today, looked at 325 patients who were discharged from hospitals run by Peninsula Health in Victoria from May to November 2017.

It found the hospital 30-day re-admission rate was cut by 66 per cent for patients who were assisted over the phone by a qualified nurse in the first month of being discharged from hospital.

“The program was supported by an algorithm developed by the Victorian Department of Health and implemented into Peninsula Health’s electronic health record system. The algorithm identified patients at risk of immediate re-admission to hospital,” senior author and Associate Professor at Monash University and National Centre for Healthy Ageing Nadine Andrew said.

Often these patients had complex health disorders, such as chronic heart and respiratory disease. They were also older and more likely to live alone. “Once we identified those at-risk patients, we allocated them a care navigator, in this case a nurse who knew the local area,” said lead author, PhD student and Peninsula Health clinician, Ms Rebecca Pang.

“Over the course of 30 days, the nurse would help coordinate the care of the patient between multiple community providers. It would begin with simple, weekly phone calls designed to help patients access follow-up healthcare services. It would also include simple, practical advice, such as reminders of upcoming appointments, corresponding with a local GP to ensure continuation of care and in some cases assisting with social needs such as transport and housing.”

The study cohort consisted of adults aged 18 and above. 262 patients received standard care when they were discharged, while 63 were assisted over the phone by a qualified health professional.

Associate Professor Andrew said the study provides preliminary evidence that targeted care navigation can bridge the gap between acute and community care and mitigate the risk of unnecessary hospital re-admission.

“Our research found important preliminary evidence that showed targeted intervention from a qualified health practitioner can greatly decrease the likelihood an at-risk patient will be re-admitted to hospital within 30 days of being discharged,” Associate Professor Andrew said.

“These patients are vulnerable and may need some extra help navigating multiple primary care providers within their community.

“It is therefore extremely important hospitals identify these patients. Using a re-admission risk algorithm appeared to be beneficial in this regard. Once we know who they are, we can put them in touch with a Care Navigation professional, who can help them with their clinical and social needs.”

Associate Professor Andrew said with Australia’s health system operating at capacity, initiatives like Targeted Care Navigation will help direct resources to where they are most needed and ease the existing strain on the healthcare system caused by an ageing population.

“While more investigation in this area is needed, our research clearly found better co-ordination between hospitals, patients and the community not only improve an individual’s health outcomes but is likely to ease the financial burden on the healthcare system by reducing unnecessary re-admissions.

“Something as simple as a phone call can make all the difference to vulnerable patients.”