Ambulatory Intensive, Multidisciplinary Telehealth for High-Risk Discharges: Program Development, Implementation, and Early Impact

Creating and implementing programs aimed at reducing readmissions for high-risk patients is critical to demonstrate quality and avoid financial penalties. Intensive, multidisciplinary interventions providing care to high-risk patients utilizing telehealth have not been explored in the literature. This study seeks to explain the quality improvement process, structure, intervention, lessons learned, and early outcomes of such a program. Patients were identified prior to discharge with a multicomponent risk score. The enrolled population was managed intensively for 30 days after discharge through a suite of services, including weekly video visits with an advanced practice provider, pharmacist, and home nurse; regular lab monitoring; telemonitoring of vital signs; and intensive home health visits. The process was iterative, including a successful pilot phase followed by an expanded health system-wide intervention analyzing multiple outcomes including satisfaction with video visits, self-rated improvement in health, and readmissions compared to matched populations. The expanded program resulted in improvements in self-reported health (68.9% reported health was some or greatly improved) and high satisfaction with video visits (89% rated satisfaction with video visits 8-10). Thirty-day readmissions were reduced compared to individuals with similar readmission risk scores discharged from the same hospital (18.3% vs 31.1%) and individuals who declined to participate in the program (18.3% vs 26.4%). This novel model using telehealth to provide intensive, multidisciplinary care to high-risk patients has been successfully developed and deployed. Key areas for growth and exploration include developing an intervention that captures a greater percentage of discharged high-risk patients, including non-homebound patients, improving the electronic interface with home health care, and reducing costs while serving more patients. Data show that the intervention results in high patient satisfaction, improvements in self-reported health, and preliminary data showing reductions in readmission rates.