title: Complex case conferences associated with reduced hospital admissions for high-risk patients with multiple comorbidities.
abstract: OBJECTIVE
  Reducing avoidable hospital readmissions presents an opportunity to improve health care quality and reduce avoidable costs. We studied the effect person-focused care may have on reducing avoidable admissions to the hospital.
  
  
  METHODS
  Among patients with heart failure discharged from the hospital, we evaluated the effect on 30-day readmissions of transitions-in-care interventions: home health visits, follow-up phone calls, and physician office visits. We also used a standardized diagnostic tool to interview readmitted patients to identify social reasons that may have contributed to the readmission. Finally, we used the learnings from both interventions to develop a new intervention: a single complex disease case conference that included the entire health care team. We measured hospital admissions for 21 patients during the 6 months before and after their complex case conferences.
  
  
  RESULTS
  Observed-over-expected hospital readmission rates were lowest for patients receiving a postdischarge visit with a home health nurse and a follow-up visit with their physician (0.54), compared with solely a physician visit (0.81), home health visit (1.2), or phone call (1.55). Various social issues may contribute to hospital readmissions, including caregiver knowledge, ability to care for oneself at home, and issues related to medications (adherence, ability to pay, and knowledge about potential side effects). Substantially fewer hospital admissions occurred after complex case conferences.
  
  
  CONCLUSIONS
  Complex case conferences with disease-focused and person-focused interventions may be associated with reduced hospital admissions for patients with heart failure and multiple comorbidities.
authors.affiliation: Care Management Institute Physician Lead for Total Health. philip.j.tuso@kp.org.
authors.forename: Philip
authors.initials: P
authors.lastname: Tuso
authors.affiliation: Senior Consultant for Kaiser Permanente Clinical Operations in Pasadena, CA. heather.l.watson@kp.org.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Watson
authors.affiliation: Performance Improvement Mentor at the Kaiser Permanente Center for Health System Performance in Oakland, CA. lynn.m.garofalo@kp.org.
authors.forename: Lynn
authors.initials: L
authors.lastname: Garofalo-Wright
authors.affiliation: Managing Director of Clinical Program Development for the Southern California Permanente Medical Group in Pasadena, CA. gail.x.lindsay@kp.org.
authors.forename: Gail
authors.initials: G
authors.lastname: Lindsay
authors.affiliation: Principal Consultant for the Care Management Institute in Oakland, CA. ana.h.jackson@kp.org.
authors.forename: Ana
authors.initials: A
authors.lastname: Jackson
authors.affiliation: Cardiologist at the Harbor City Medical Center in CA. maria.t.taitano@kp.org.
authors.forename: Maria
authors.initials: M
authors.lastname: Taitano
authors.affiliation: Regional Heart Failure Champion Physician Co-Lead at the Baldwin Park Medical Center in CA. sandra.y.koyama@kp.org.
authors.forename: Sandra
authors.initials: S
authors.lastname: Koyama
authors.affiliation: Regional Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group in Pasadena, CA. michael.h.kanter@kp.org.
authors.forename: Michael
authors.initials: M
authors.lastname: Kanter
mesh_terms: D000359:Aftercare; D019090:Case Management / Q000458:organization & administration*; D015897:Comorbidity; D006333:Heart Failure / Q000628:therapy*; D006699:Home Care Services; D006801:Humans; D010359:Patient Readmission / Q000706:statistics & numerical data*; D018802:Patient-Centered Care / Q000379:methods*