A Population Health Approach to Transitional Care Management for High-Risk Patients with Diabetes: Outcomes at a Rural Hospital.

Patient transitions from inpatient to home care are an important area of focus for reducing costly unplanned hospital readmissions. In rural settings, the challenge of reducing unplanned readmissions is amplified by limited access to both ambulatory and acute care as well as high levels of social disadvantage. In addition, there is a scarcity of evidence regarding strategies that have been proven to improve care transitions and related patient outcomes in this setting. This paper describes the process for implementation and results of a telephone-based transitional care management (TCM) program designed to reduce readmissions for patients with diabetes in a rural hospital in Scotland County, North Carolina. Data were collected from July 2016 to January 2019 using billing records to identify adult patients with high or very high risk of readmission based on length of stay, acuity, comorbidity, and emergency department visits (LACE) scores. Care managers contacted eligible patients by phone after discharge to review discharge instructions, assess need for home health services and transportation assistance, and schedule primary care follow-up visits. Overall, 13.8% of 15,271 discharges were targeted for TCM; 68.2% of these involved a patient with diabetes. The post-intervention 30-day readmission rate was 18.0% among patients identified as high or very high risk versus 8.8% among the overall population and did not differ significantly between TCM participants with diabetes and those without (22.9% vs.18.8%; P = 0.525). Findings highlight challenges with implementing transition of care interventions in rural settings, which include staffing, patient volume, and accessing data from out-of-network providers.

Behavioral Treatment of Self-Injury: 2001 to 2016.

Individuals diagnosed with intellectual and developmental disabilities (IDD) frequently exhibit self-injurious behavior (SIB). Previous research has examined the published literature on behavioral treatments of SIB from 1964-2000. Results suggested that these treatments were highly efficacious at decreasing SIB, particularly when based on the results of a functional assessment. The purpose of this review is to update, replicate, and extend the previous research. The current findings indicate an increase in studies reporting automatically maintained SIB as well as less efficacious treatments overall. Discussion of our conclusions and methods of SIB assessment and treatment are discussed, both as they relate to the previous review and for future directions.

Measuring and treating serum lipids in patients in a chest pain observation unit.

We evaluated opportunities to initiate statin therapy in 574 consecutive subjects admitted to a chest pain observation unit (CPOU). Ten-year Framingham risk scores were retrospectively calculated for all patients according to the National Cholesterol Education Program and Adult Treatment Panel III 2001 recommendations. Subjects were then stratified according to (1) recommendations for initiation of a lipid-lowering medication and (2) whether they received lipid-lowering drug therapy at discharge. Of 574 subjects, we excluded 50 with previously established coronary heart disease or who were already taking a statin medication on presentation, 23 with missing data, and 80 who did not have a low-density lipoprotein (LDL) measurement at admission. Of the remaining 421 subjects, the mean age was 47 years, 40% were men, 57% were white, 31% had hypertension, 27% were current smokers, and 6% had diabetes. Ten-year risk calculation classified 47% (n=199) at low risk (<2 risk factors), 32% (n=134) at moderate risk (>or=2 risk factors and <10% risk), 11% (n=48) at moderate-high risk (10% to 20% risk), and 10% (n=40) at high risk (>20% risk). Of the entire cohort, 23% of subjects (n=96) had hypercholesterolemia, of which 52% (n=50) met indications for initiation of lipid-lowering medication. Only 6% of patients with an indication for treatment (n=3) were prescribed a lipid-lowering medication on discharge, leaving 94% (n=47) untreated for their hypercholesterolemia. In conclusion, patients admitted to a CPOU have a high prevalence of hypercholesterolemia, and therefore, an increased long-term risk for cardiovascular events. In addition to their primary role, CPOUs should focus on primary prevention and reduction of long-term risk.