Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home.

08:00 EDT 11th October 2019 | BioPortfolio

Summary of "Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home."

To determine whether a specialized medical home can reduce re-hospitalizations and emergency department (ED) visits as compared to reports in the literature for persons with spinal cord injury (SCI) in the first year post-discharge from acute inpatient rehabilitation. A three-year prospective cohort study. An academic free standing inpatient rehabilitation hospital (IRF), participating in the SCI Model Systems network, serving urban, rural and suburban settings in the mid-Atlantic region of the United States of America. 176 successive individuals with varying levels of SCI, inclusive of patients requiring mechanical ventilation, discharged from rehabilitation from 2/1/15 to 7/1/17, who met criteria and consented to participate. Pre-discharge communication between the inpatient and outpatient staff was initiated, medication education by a pharmacist was added, 1 month of discharge medications was offered, and proactive phone calls to patients after discharge were instituted. In addition, patients were offered a 24/7 hotline to reach physician and nursing staff, and multidisciplinary outpatient follow-up was provided in conjunction with extensive proactive case management. All-cause hospital readmission and ED visits. Thirty percent of the individuals were readmitted within the first year after discharge from an IRF, and 24% were readmitted within the first year after onset. The incidence of readmission was 0.46 and 0.36 respectively. Forty-one percent had an ED visit. The results suggest that the medical home interventions decreased the rate and incidence of readmission and the rate of ED usage in the first year.


Journal Details

This article was published in the following journal.

Name: The journal of spinal cord medicine
ISSN: 2045-7723
Pages: 1-8


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