A unique University of Michigan Health System program that helps older patients transition from the hospital to sub-acute care facilities has significantly reduced hospital stays and readmissions, according to new findings published in the Journal of the American Medical Directors Association.
Creating seamless patient transfers between hospitals and long-term care facilities has become a growing national concern. Previously reported studies have shown that these patients are particularly vulnerable to medication errors, hospital readmissions and other adverse effects on their care.
The six-year-old UMHS Sub-Acute Care Service - which coordinates care between the hospital and care facilities commonly called nursing homes - has proven a successful model of providing safe transitions for hospitalized patients. The average length of stay at UMHS before transfer to a skilled nursing facility dropped from 10.6 days to eight days, and hospital inpatient stays for patients in the program were reduced by nearly 2,908 days a year, authors say.
The findings come as new Medicare data released this month show that hospital readmissions continue to be a big problem in healthcare, with one in five Medicare patients returning to the hospital within a month of discharge.
The UMHS paper - whose lead author is U-M geriatric physician Darius K. Joshi, M.D.,- appears alongside a JAMDA editorial that lauds the U-M transition program.
"The data presented by Joshi and colleagues are compelling and the program ought to be monitored as a potential model for other health systems," reads the editorial, titled "Climbing out of the Black Hole of Subacute Care."
The UMHS sub-acute care program involves a close partnership between UMHS and selected skilled nursing facilities in the Ann Arbor area. It has dramatically changed the relationship between the hospital and facilities by deploying U-M physicians and nurse practitioners to skilled nursing facility partners. This U-M team follows patients after discharge and manages their care on-site.
"These patients are often elderly with chronic illness and other health concerns and require medical care and rehabilitation in skilled nursing facilities after hospitalization," says Joshi, who is director of the sub-acute program and a clinical instructor in the geriatric medicine division of the U-M Medical School's Department of Internal Medicine.
"We aimed to break down the silos that are such a big problem in healthcare and improve the continuity of care. We found that an investment like this by a large health system does produce returns by improving the overall quality of coordinated care for patients discharged to care facilities."