title: Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: A Randomized Controlled Trial.
abstract: BACKGROUND
  Emerging evidence from the virtual ward care model showed that multidisciplinary case management are inadequate to reduce readmissions or death for high risk patients. There is consensus that interventions should encompass both pre-hospital discharge and post-discharge transitional care to be effective. Integrated practice units (IPU) had been proposed as an approach of restructuring the organization and work processes of multidisciplinary teams to achieve value in healthcare. Our primary objective is to evaluate if the novel application of the IPU concept to organize a modified virtual ward model incorporating pre-hospital discharge transitional care can reduce readmissions of patients at highest risk for readmission.
  
  
  METHODS
  We conducted an open label, assessor blinded randomized controlled trial on patients with one or more unscheduled readmissions in the prior 90 days and LACE score ≥ 10. 840 patients were randomized in 1:1 ratio and blocks of 6 to the intervention program (n = 420) or control (n = 420). Allocation concealment was effected via an off-site telephone service maintained by a hospital administrator. Intervention patients received discharge planning, medication reconciliation, coaching on self-management of chronic diseases using standardized action plans and an individualized care plan complete with written discharge instructions, appointments schedule, medication changes and the contact information of the outpatient VW nurse before discharge. At discharge, care is handed over to the outpatient VW team. Patients were closely monitored in the VW for three months that included a telephone review within 72 hours of discharge, home assessment, regular telephone reviews to identify early complications and early review clinics for patients who destabilize. The VW meet daily to discuss new patients and review care plans for patients. Control patients received standard hospital care that included a standardized patient copy of the hospital discharge summary listing their medical diagnoses and medications; and follow up is arranged with a primary care provider or specialist as considered necessary. The primary outcome was the unplanned readmission rate to any hospital within 30 days of discharge. Secondary outcomes included the unplanned readmission rate, emergency department (ED) attendance rate to any hospital and the probability without readmission or death up to 180 days of discharge. Length of stay and mortality rate at 90-day were compared between the two groups. Outcome data were objectively retrieved from the hospital and National Electronic Health Records by a blinded outcome assessor.
  
  
  RESULTS
  All patients' outcomes were included in an intention-to-treat analysis. The characteristics of both study groups were similar. Patients in the intervention group had a significant reduction in the number of 30-day readmissions, IRR 0.67 (95% CI, 0.52 to 0.86, p = 0.001) and the number of 30-day emergency department attendances, IRR 0.60 (95% CI, 0.46 to 0.79, p<0.001) compared to those receiving standard hospital care. The effectiveness was sustained at 90 and 180 days. The intervention group utilized 1164 fewer hospital bed days at 90-day post discharge. No adverse events were reported.
  
  
  CONCLUSIONS
  Applying the integrated practice unit concept to the virtual ward program resulted in reduced readmissions in patients who are at highest risk of readmission.
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Lian Leng
authors.identifier: http://orcid.org/0000-0003-4228-2862
authors.initials: LL
authors.lastname: Low
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Shu Yun
authors.identifier: http://orcid.org/0000-0003-0307-9546
authors.initials: SY
authors.lastname: Tan
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Matthew Joo Ming
authors.initials: MJ
authors.lastname: Ng
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Wei Yi
authors.identifier: http://orcid.org/0000-0003-1354-0439
authors.initials: WY
authors.lastname: Tay
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Lee Beng
authors.identifier: http://orcid.org/0000-0002-8599-1186
authors.initials: LB
authors.lastname: Ng
authors.affiliation: Health Services Research, Medicine Academic Clinical Program, Singapore General Hospital, Singapore.
authors.forename: Kanchana
authors.initials: K
authors.lastname: Balasubramaniam
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.
authors.forename: Rachel Marie
authors.initials: RM
authors.lastname: Towle
authors.affiliation: Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore.|Family Medicine, Duke-NUS Medical School, Singapore.
authors.forename: Kheng Hock
authors.identifier: http://orcid.org/0000-0001-5841-6277
authors.initials: KH
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D003198:Computer Simulation; D003266:Continuity of Patient Care; D004636:Emergency Service, Hospital; D005260:Female; D006739:Hospital Administration; D006801:Humans; D033183:Interdisciplinary Communication; D007902:Length of Stay; D008297:Male; D059065:Medication Reconciliation; D008875:Middle Aged; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge; D010359:Patient Readmission; D012306:Risk; D018401:Sample Size; D012846:Singapore; D055815:Young Adult