Please use this identifier to cite or link to this item: https://doi.org/10.5334/ijic.3050
Title: Transitional home care program utilizing the integrated practice unit concept (THC-IPU): Effectiveness in improving acute hospital utilization
Authors: Low, L.L 
Tay, W.Y 
Tan, S.Y 
Chia, E.H.S
Towle, R.M
Lee, K.H 
Keywords: case manager
control group
controlled study
education
emergency ward
female
home care
home visit
hospital discharge
hospital physician
hospital readmission
hospital utilization
human
major clinical study
male
medication therapy management
transitional care
Issue Date: 2017
Publisher: Ubiquity Press Ltd
Citation: Low, L.L, Tay, W.Y, Tan, S.Y, Chia, E.H.S, Towle, R.M, Lee, K.H (2017). Transitional home care program utilizing the integrated practice unit concept (THC-IPU): Effectiveness in improving acute hospital utilization. International Journal of Integrated Care 17 (4) : 5. ScholarBank@NUS Repository. https://doi.org/10.5334/ijic.3050
Abstract: Background: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation. Methods: 1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge. Results: We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders. Conclusion: Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions. © 2017 The Author(s).
Source Title: International Journal of Integrated Care
URI: https://scholarbank.nus.edu.sg/handle/10635/173838
ISSN: 15684156
DOI: 10.5334/ijic.3050
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