Evaluation of Integrated Care Model for Post-discharged High-risk Elderly Patients on Hospital Readmission, Mortality, Accident and Emergency Department Attendance and New Recruitment in Elderly Home

Objectives: To examine the associations between post-discharge care, the Integrated Care Model (ICM) targeting older patients with a high risk of readmission, and risk of short-, medium-, long-term readmission, emergency department visits, mortality, and new residence of elderly home in a large, integrated healthcare system.

Methods:
Design
An Electric-Health-Record-(EHR) based matched cohort design.
Setting
All major public hospitals in Hong Kong.
Participants
41,513 home-dwelling older patients above the age of 60 who were alive discharges with post-implementation of the ICM between Jan 01, 2012, and June 30, 2019, and 41,513 older patients without ICM, matched by propensity score within strata of admission age and sex, and followed up to Dec 31, 2019.
Intervention
Older patients above age 60, were recruited into ICM by a hospitalized readmission risk assessment and then underwent community-coordinated post-discharged home visits by medical staff.

Results:
Risk estimates indicated that ICM was associated with significantly reduced risk of
30-, 90-, 180-day readmission (30-day adjusted OR = 0.45 95%CI 0.43 – 0.46; 90-day adjusted OR = 0.51 95%CI 0.50 – 0.53; 180-day adjusted OR = 0.63 95%CI 0.61 – 0.65);
30-, 90-, 180-day emergency visit (30-day adjusted OR = 0.53 95%CI 0.51 – 0.55; 90-day adjusted OR = 0.60 95%CI 0.58 – 0.62; 180-day adjusted OR = 0.72 95%CI 0.70 – 0.75);
90- and 180-day mortality (90-day adjusted OR = 0.87 95%CI 0.82 – 0.92; 180-day adjusted OR = 0.84 95%CI 0.80 – 0.87) with exception of short-term mortality (30-day adjusted OR = 1.09 95%CI 0.98 – 1.21);
New residence in elderly home (180-day adjusted OR = 0.73 95%CI 0.71 – 0.75).

Conclusions:
In an integrated health system, post-discharge care has a positive impact of a reduction in risk of short-, medium-, long-term readmission, emergency department visits, mortality, and new residence of elderly home.