University of Wisconsin–Madison Medical College of Wisconsin

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

Brian C. Hilgeman, MD; Geoffrey Lamb, MD

WMJ. 2023:122(1):26-31.

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Introduction: 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.

Methods: 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.

Results: 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 on a scale of 0-10). Thirty-day readmissions were reduced compared to individuals with similar readmission risk scores discharged from the same hospital (18.3% vs 26.4%) and individuals who declined to participate in the program (18.3% vs 31.1%).

Conclusions: 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 and improvements in self-reported health, with preliminary data showing reductions in readmission rates.

Author Affiliations: Department of Medicine, Division of General Internal Medicine, Section of Primary Care, Medical College of Wisconsin (MCW); Milwaukee, Wisconsin (Hilgeman); Department of Medicine, Division of General Internal Medicine, Section of Hospital Medicine; MCW, Milwaukee, Wis (Lamb).
Corresponding Author: Brian Hilgeman, MD, 9200 W Wisconsin Ave, Milwaukee, WI 53226; phone 414.955.0365; email; ORCID ID 0000-0001-7158-091X
Funding/Support: None declared.
Financial Disclosures: None declared.
Acknowledgements: The authors wish to acknowledge Lee Biblo, MD, Stacy Wolf BSN, RN, CDE, Darcey Hagemann PA-C, Catherine English APNP, Janice Cleveland BSN-RN, Andre Simms, Andres Sercovich PharmD, Calloway VanEpern PharmD, Roberta Schmidt, Colleen Schmidt for their cotributions to the conceptualization, development, and operationalization of this project.
Data Availability: Data stored securely and available upon request from the corresponding author.
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