Reducing hospital readmission through team-based primary care: A 7-week pilot study integrating behavioral health and pharmacy.
Fam Syst Health
; 35(2): 217-226, 2017 Jun.
Article
en En
| MEDLINE
| ID: mdl-28617022
ABSTRACT
INTRODUCTION:
A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings.METHOD:
A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients' mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model.RESULTS:
Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success.DISCUSSION:
Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems' costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record
Texto completo:
1
Colección:
01-internacional
Asunto principal:
Readmisión del Paciente
/
Farmacia
/
Atención Primaria de Salud
/
Medicina de la Conducta
Tipo de estudio:
Guideline
/
Prognostic_studies
Límite:
Adult
/
Aged
/
Female
/
Humans
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Male
/
Middle aged
País/Región como asunto:
America do norte
Idioma:
En
Revista:
Fam Syst Health
Asunto de la revista:
PSICOLOGIA
Año:
2017
Tipo del documento:
Article