Examining the impact of an interprofessional team model of care on 30-day readmissions
Hospital readmissions within 30 days of discharge are a common indicator of poor quality of care and a source of financial penalties for hospitals. Reducing readmissions requires effective care transitions that involve coordination and communication among different health professionals across different settings. Interprofessional team models of care are one way to achieve this goal, as they involve collaboration among various disciplines to provide patient-centered and holistic care. This paper aims to examine the impact of an interprofessional team model of care on 30-day readmissions, using evidence from recent studies and literature.
An interprofessional team model of care is defined as “a group of individuals from different disciplines who work together to deliver comprehensive services that address as many of the patient’s health and other needs as possible” [1]. The core components of this model include shared goals, clear roles, mutual trust, effective communication, and measurable outcomes [2]. Interprofessional teams can vary in their composition, structure, and function depending on the context and the patient population. For example, some teams may include physicians, nurses, pharmacists, social workers, dietitians, physical therapists, occupational therapists, and case managers, while others may have fewer or different members. Some teams may be co-located in the same unit or clinic, while others may be dispersed across different settings. Some teams may have regular meetings and rounds to discuss patient care plans, while others may rely on electronic tools and platforms to communicate and coordinate [3].
The benefits of interprofessional team models of care for patients include improved quality and safety of care, enhanced patient satisfaction and engagement, reduced fragmentation and duplication of services, increased access to comprehensive and coordinated care, and improved health outcomes and well-being [4]. For health professionals, interprofessional team models of care can foster mutual learning and respect, enhance professional development and satisfaction, reduce workload and stress, and improve clinical decision making and problem solving [5].
Several studies have examined the impact of interprofessional team models of care on 30-day readmissions, especially for older patients and patients with chronic conditions. A systematic review by Pugh et al. [6] found that interprofessional team models of care reduced 30-day readmissions by 12% compared to usual care for older patients admitted to acute care for elders (ACE) units. ACE units are specialized hospital units that provide geriatric-focused care by an interprofessional team that includes a geriatrician or geriatric nurse practitioner, a nurse manager, a clinical nurse leader, a pharmacist, a social worker, a physical therapist, an occupational therapist, a nutritionist, a chaplain, a discharge planner, and a unit clerk [7]. The review also found that interprofessional team models of care improved adherence to evidence-based geriatric care processes, patient functional status at discharge, length of stay, and costs.
Another systematic review by Karam et al. [8] found that interprofessional team models of care reduced 30-day readmissions by 18% compared to usual care for patients with chronic heart failure (CHF). CHF is a common condition that requires complex management and frequent hospitalizations. Interprofessional team models of care for CHF patients typically involve a cardiologist or a nurse practitioner with cardiology expertise, a nurse educator or case manager, a pharmacist, a dietitian, a social worker or psychologist,
and other allied health professionals as needed [9]. The review also found that interprofessional team models of care improved patient self-care behaviors, quality of life, mortality, and costs.
A recent observational study by Pugh et al. [10] found that the number of evidence-based transitional care processes used by interprofessional teams was correlated with lower 30-day readmission rates for veterans admitted to VA hospitals. Transitional care processes are interventions that aim to ensure continuity and coordination of care during transitions between different settings or levels of care. The study identified 20 recommended transitional care processes based on literature review and expert consensus. These processes included pre-discharge patient education, medication reconciliation prior to discharge,
patient inclusion in discharge planning,
post-discharge follow-up phone calls,
timely communication with primary care providers,
and increased utilization of community supports [10]. The study found that no site performed all 20 processes consistently,
and that sites with higher total scores had lower risk-standardized readmission rates.
These studies suggest that interprofessional team models of care can have a positive impact on 30-day readmissions by improving the quality and coordination of care across the continuum. However,
there are also challenges and barriers to implementing and sustaining interprofessional team models of care in practice. These include organizational factors such as lack of leadership support,
inadequate resources,
incompatible information systems,
and conflicting policies; professional factors such as role ambiguity,
lack of training,
poor communication,
and power imbalances; and patient factors such as low health literacy,
complex needs,
and preferences [11]. Therefore, further research and evaluation are needed to identify the best practices and strategies to overcome these challenges and to optimize the effectiveness and efficiency of interprofessional team models of care for different patient populations and settings.
References
[1] World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO; 2010.
[2] Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017;6:CD000072.
[3] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Hum Resour Health. 2013;11:19.
[4] Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;3:CD000
