Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge

Reducing hospital admissions and improving transitional care, as described by Jackson et al.,[1] and improvement of outpatient follow-up are important issues in Brazil, a developing country that is going through the same epidemiological transition observed in developed countries. The elderly, an increasing population facing high levels of disability,[2] especially from chronic diseases, currently account for the highest share of hospitalization costs in Brazil.[3]

In recognition of the need to prevent repeated readmissions that would severely compromise the public health system in Brazil - which provides free, universal care -, in 2011 the Ministry of Health launched the "Better Home Program" (BHP), standardizing and expanding the coverage of pre-existing home care services to encompass transitional care with hospital discharge planning and follow-up. Currently, the BHP covers 50 million people.

As part of BHP, the Home Care Program at Grupo Hospitalar Conceicao (HCP/GHC), an 850-bed hospital located in the Rio Grande do Sul state capital Porto Alegre, serves around 910 patients per year. Six teams including physicians, nurses, and nursing technicians, supported by a dietician, a physical therapist, and a social worker handle transitional care for 80 new patients per month on average, beginning prior to hospital discharge and continuing until the patient is considered to be apt for regular care at a primary care unit (often beyond 40 days).

The follow-up visits are weekly. Patients are selected based on clinical goals, caregiver presence mediation and defined territory. The mean Charlson Index for the patients followed by the HCP is 3.5. HCP/GHC is cost-effective: US$ 47 vs. US$ 194 per patient per day for a hospital bed. The readmission rate for PAD/GHC is about 16,7% in 30 days.

Despite the differences in the model of transitional care practiced by HCP/GHC and that described by Jackson and colleagues, we wonder if segmentation based on risk of 30-day readmission would have an impact on patient selection and on the results obtained so far by HCP/GHC - and what this impact would be.

The literature shows that contextualized analysis of hospital readmissions is important, since the predictors include inherent patient characteristics (gender, age and ethnicity), clinical aspects associated with comorbidities, and social problems related to environment, culture, education, and income.[4] Adding risk segmentation to that bundle may provide additional opportunities for improvement in health systems that are hard pressed to decrease, and prevent, hospital readmissions.

1. Jackson C, Shahsahebi M, Wedlake T, Dubard CA. Timeliness of outpatient Follow-Up: An Evidence-Based approach for planning after hospital discharge. Ann Fam Med 2015;13(2):115-22.
2. Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: Quantifying the epidemiological transition. Lancet 2015;386(10009):2145-91.
3. Ministerio da Saude, Secretaria de Atencao a Saude D de AB. Manual de monitoramento e avaliacao: Programa Melhor em Casa. 2014.
4. Wong ELY, Cheung AWL, Leung MCM, et al. Unplanned readmission rates, length of hospital stay, mortality, and medical costs of ten common medical conditions: a retrospective analysis of Hong Kong hospital data. BMC Health Serv Res [Internet] 2011;11(1):149. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146405/

Competing interests: None declared