Managing Transitions for Complex Medical Patients

HPME faculty members Walter Wodchis and Geoff Anderson – who belong to the Health System Performance Research Network (HSPRN) – are engaged in research that is changing the way we understand how certain patients use health-care services and the burden such use places on the health system. They are conducting their studies in collaboration with fellow HPME faculty members G. Ross Baker, Elizabeth Lin, Astrid Guttman, and Irfan Dhalla.

"Our research is at the start of a program aimed at transforming conceptions of performance measurement," Wodchis says. “We hope to contribute to a move away from a provider-focused approach to a patient-centered approach – one that tracks the effective management of patients throughout the healthcare system.”

Populations with complex medical conditions, high health utilization rates, and who move from one sector to another (for example from acute hospitals to community) represent an important opportunity to improve quality and reduce health-care costs. The HSPRN team is focusing its analysis on three such patient groups: older adults with multiple chronic or complex acute medical conditions; adults with psychotic disorders; and children with complex medical conditions.

In particular, the researchers are examining transitions between health-care providers, beginning with the transition from acute to community among older adults. To date, Wodchis and his colleagues have uncovered the importance of early follow-up care as a key strategy in reducing hospital readmissions.

At the Canadian Association for Health Services and Policy Research conference held in Toronto in May 2010, Wodchis presented results showing that a nursing visit in the home within one day after acute discharge is associated with a 30 per cent reduction in all-cause readmissions to acute care within 30 and 90 days. Meanwhile, a primary care visit within 7 days after discharge is associated with a 15 per cent reduction in 90-day readmissions.