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Study Questions:
Does the Camden Core Model care transitions program improve hospital readmissions 180 days after discharge in patients with medically and socially complex conditions?
Methods:
Over a 39-month period, 800 patients from 2 hospitals in Camden, New Jersey, with frequent hospital admissions were identified as super-utilizers using the following criteria: at least 1 admission in the 6 months prior to the index admission, 2 or more chronic health conditions, and a minimum 2 of the following 6 criteria:
- More than 5 medications
- Difficulty accessing services
- Mental illness
- An active drug habit
- Homelessness
- Lack of social support
They were randomly assigned to usual care or to the Camden Core Model, a care transitions program comprising initial contact during an inpatient hospital stay followed by intensive outpatient follow-up by a multidisciplinary care team. This included home visits, referral to social service agencies such as housing agencies and addiction treatment, accompanying patients to appointments, self-care coaching, and interventions such as measuring of blood pressure and blood sugar.
Results:
The primary outcome was readmission within 180 days from index admission. Other outcomes measured within the 180-day period post-discharge included number of readmissions, number of patients with 2 or more readmissions, hospital days, charges, payments received, and mortality. At 180 days, the readmission rates were slightly worse in the treatment group compared with the usual care group (62.34 and 61.70, respectively), with the adjusted difference in the probability of readmission being 0.82 percentage points higher (95% confidence interval, 5.97-7.61; p = 0.81.) Regarding patient characteristics, over half were between 45 and 64 years old (55.4%), and 27.5% were 65 years or older. In terms of ethnicity, 54.9% were black, 29.5% were Hispanic, and 15.1% were non-Hispanic white. Regarding mental health, 30.2% had a diagnosis of depression, and 44% had a diagnosis of active substance abuse. Over a third of patients in both groups had greater than 2 readmissions, so at least 3 admissions in the 180-day period (36.39 in the treatment group and 36.25 in the control group). Regarding interventions, patients in the treatment group received an average of 7.6 home visits, 8.8 phone calls, and 2.5 primary care and specialty visits, with an average of 28.1 total encounters.
Conclusions:
During the study period, the Camden Core Model’s intensive intervention model was not shown to reduce readmissions at 180 days. This was not consistent with findings from other intensive transitional care programs that improved readmissions but served a narrower scope of patients.
Perspective:
In recent years, much attention has been focused on the 5% of our population that accounts for 50% of annual healthcare spending. Some studies have shown that transitional care programs with strong discharge planning, multidisciplinary care teams, and in-home follow-up reduce readmissions, but these programs did not fully represent the social and medical complexity of so many super-utilizer patients. This much-anticipated study, with its disappointing results, has nonetheless sparked a robust and useful conversation about how we care for super-utilizer patients. In a The New York Times op ed, Dr. Jeffrey Brenner, who founded the Camden Project, was quoted “we’re coordinating care to nowhere,” referring to navigating patients to substandard housing and inadequate addictions intervention. Dr. Brenner identified a possible lesson learned and an area of opportunity to target moving forward. The piece also pointed out that the study’s design did not assess whether certain types of patients such as those over 65 or those who had secure housing did benefit from the program, as the patients studied in more focused transitional care programs had. And in the same month that JACC: Heart Failure published a critical position paper on the impact of the Heart Failure Readmission Reduction program, the study calls into question major policy initiatives that are not evaluated with a randomized controlled trial but nevertheless continue to drive healthcare spending and outcomes. Although these findings are frustrating, they point the way to more studies on the care we deliver to our most vulnerable patients. These problems are the result of deeply rooted multigenerational, systemic social problems such as poverty, racism, and violence that our culture struggles to understand every day.
Keywords: Continuity of Patient Care, Ambulatory Care, Patient Readmission, Patient Discharge, Outpatients, Patient Navigation, New Jersey, Referral and Consultation, Appointments and Schedules, Social Work, Social Support, Homeless Persons, Mental Health, Poverty
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