Hospital Admission and Discharge: Lessons Learned from a Large Programme in Southwest Germany
By: Johanna Forstner, Maximilian Pilz, Cornelia Straßner, Aline Weis, Nicola Litke, Lorenz Uhlmann, Frank Peters-Klimm, Frank Aluttis, Annika Baldauf, Marion Kiel, Markus Qreini, Petra Kaufmann-Kolle, Janina Schubert-Haack, Nadja El-Kurd, Katrin Tomaschko-Ubeländer, Sarah Treffert, Ronja Rück, Bärbel Handlos, Gökce Karakas, Michel Wensing and Joachim Szecsenyi
References
- Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. Canadian Medical Association Journal. 2004; 170(3): 345–9.
- Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine. 2003; 18(8): 646–51. DOI: 10.1046/j.1525-1497.2003.20722.x
- Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297(8): 831–41. DOI: 10.1001/jama.297.8.831
- van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of General Internal Medicine. 2002; 17(3): 186–92. DOI: 10.1046/j.1525-1497.2002.10741.x
- Hesselink G, Flink M, Olsson M, Barach P, Dudzik-Urbaniak E, Orrego C, et al. Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Quality & Safety. 2012; 21(Suppl 1): i39–49. DOI: 10.1136/bmjqs-2012-001165
- Straßner C, Hoffmann M, Forstner J, Roth C, Szecsenyi J, Wensing M. Interventions to Improve Hospital Admission and Discharge Management: An Umbrella Review of Systematic Reviews. Quality management in health care. 2020; 29(2): 67–75. DOI: 10.1097/QMH.0000000000000244
- Hesselink G, Zegers M, Vernooij-Dassen M, Barach P, Kalkman C, Flink M, et al. Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC health services research. 2014; 14: 389. DOI: 10.1186/1472-6963-14-389
- Leppin AL, Gionfriddo MR, Kessler M, Brito JP, Mair FS, Gallacher K, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA internal medicine. 2014; 174(7): 1095–107. DOI: 10.1001/jamainternmed.2014.1608
- Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Annals of internal medicine. 2011; 155(8): 520–8. DOI: 10.7326/0003-4819-155-8-201110180-00008
- Mistiaen P, Francke AL, Poot E. Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Services Research. 2007; 7: 47. DOI: 10.1186/1472-6963-7-47
- Scott IA. Preventing the rebound: improving care transition in hospital discharge processes. Australian health review: a publication of the Australian Hospital Association. 2010; 34(4): 445–51. DOI: 10.1071/AH09777
- Schlette S, Lisac M, Blum K. Integrated primary care in Germany: the road ahead. International Journal of Integrated Care. 2009; 9:
e14 . DOI: 10.5334/ijic.311 - Kringos DS, Boerma WGW, van der Zee J, Groenewegen PP. Political, cultural and economic foundations of primary care in Europe. Social science & medicine (1982). 2013; 99: 9–17. DOI: 10.1016/j.socscimed.2013.09.017
- Freytag A, Biermann J, Ochs A, Lux G, Lehmann T, Ziegler J, et al. The Impact of GP-Centered Healthcare. Deutsches Arzteblatt international. 2016; 113(47): 791–8. DOI: 10.3238/arztebl.2016.0791
- Wensing M, Kolle PK, Szecsenyi J, Stock C, Laux G. Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study. Scandinavian Journal of Primary Health Care. 2018; 36(2): 109–14. DOI: 10.1080/02813432.2018.1459429
- Wensing M, Szecsenyi J, Stock C, Kaufmann Kolle P, Laux G. Evaluation of a program to strengthen general practice care for patients with chronic disease in Germany. BMC Health Services Research. 2017; 17(1): 62. DOI: 10.1186/s12913-017-2000-2
- Brooke BS, Stone DH, Cronenwett JL, Nolan B, DeMartino RR, MacKenzie TA, et al. Early primary care provider follow-up and readmission after high-risk surgery. JAMA surgery. 2014; 149(8): 821–8. DOI: 10.1001/jamasurg.2014.157
- Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. Journal of General Internal Medicine. 2008; 23(8): 1228–33. DOI: 10.1007/s11606-008-0618-9
- Lee KH, Low LL, Allen J, Barbier S, Ng LB, Ng MJM, et al. Transitional care for the highest risk patients: findings of a randomised control study. International Journal of Integrated Care. 2015; 15:
e039 . DOI: 10.5334/ijic.2003 - Goodwin N. Understanding Integrated Care. International Journal of Integrated Care. 2016; 16(4): 6. DOI: 10.5334/ijic.2530
- AQUA – Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH. Entlassungsmanagement – Konzeptskizze für ein Qualitätssicherungsverfahren. Göttingen; 2015. [cited 2022 Feb 25]. Available from:
https://sqg.de/sqg/upload/CONTENT/Neue-Verfahren/Entlassungsmanagement/Bericht_Konzeptskizze_Entlassungsmanagement.pdf . - Erweitertes Bundesschiedsamt für die vertragsärztliche Versorgung. Rahmenvertrag über ein Entlassmanagement beim Übergang in die Versorgung nach Krankenhausbehandlung nach § 39 Abs. 1a S. 9 SGB V (Rahmenvertrag Entlassmanagement); 2016.
- Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health System Review. Health systems in transition. 2020; 22(6): 1–272.
- Möller K-H, Makoski K. Der Arztbrief – Rechtliche Rahmenbedingungen. KrV Kranken- und Pflegeversicherung 2015; 5. DOI: 10.37307/j.2193-5661.2015.05.05
- Forstner J, Bossert J, Weis A, Litke N, Strassner C, Szecsenyi J, Wensing M. The role of personalised professional relations across care sectors in achieving high continuity of care. BMC Family Practice. 2021; 22(1): 72. DOI: 10.1186/s12875-021-01418-8
- Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: Who are the healthcare professionals in the primary care teams across the world? International journal of nursing studies. 2015; 52(3): 727–43. DOI: 10.1016/j.ijnurstu.2014.11.014
- Mergenthal K, Beyer M, Gerlach FM, Güthlin C. Wie werden Delegationskonzepte in Hausarztpraxen ausgestaltet? Eine Analyse am Beispiel der VERAH in der HzV. Zeitschrift für Allgemeinmedizin. 2016; 92(10): 402–7. DOI: 10.3238/zfa.2016.0402–;0407
- Donzé JD, Williams MV, Robinson EJ, Zimlichman E, Aujesky D, Vasilevskis EE, et al. International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions. JAMA internal medicine. 2016; 176(4): 496–502. DOI: 10.1001/jamainternmed.2015.8462
- Forstner J, Litke N, Weis A, Straßner C, Szecsenyi J, Wensing M. How to fall into a new routine: factors influencing the implementation of an admission and discharge programme in hospitals and general practices. BMC Health Services Research. 2022; 22(1): 1289. DOI: 10.1186/s12913-022-08644-5
- Forstner J, Kunz A, Straßner C, Uhlmann L, Kuemmel S, Szecsenyi J, Wensing M. Improving Continuity of Patient Care Across Sectors: Study Protocol of the Process Evaluation of a Quasi-Experimental Multi-Centre Study Regarding an Admission and Discharge Model in Germany (VESPEERA). BMJ Open. 2019; 9(11):
e031245 . DOI: 10.1136/bmjopen-2019-031245 - Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA. 2014; 312(22): 2401–2. DOI: 10.1001/jama.2014.16153
- Kontopantelis E, Doran T, Springate DA, Buchan I, Reeves D. Regression based quasi-experimental approach when randomisation is not an option: interrupted time series analysis. BMJ (Clinical research ed.) 2015; 350: h2750. DOI: 10.1136/bmj.h2750
- Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014; 348: g1687. DOI: 10.1136/bmj.g1687
- Forstner J, Straßner C, Kunz A, Uhlmann L, Freund T, Peters-Klimm F, et al. Improving continuity of patient care across sectors: study protocol of a quasi-experimental multi-centre study regarding an admission and discharge model in Germany (VESPEERA). BMC health services research. 2019; 19(1): 206. DOI: 10.1186/s12913-019-4022-4
- Huang Y-q, Gou R, Diao Y-s, Yin Q-h, Fan W-x, Liang Y-p, et al. Charlson comorbidity index helps predict the risk of mortality for patients with type 2 diabetic nephropathy. Journal of Zhejiang University SCIENCE B. 2014; 15(1): 58–66. DOI: 10.1631/jzus.B1300109
- Facchinetti G, D’Angelo D, Piredda M, Petitti T, Matarese M, Oliveti A, Marinis MG de. Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. International journal of nursing studies. 2020; 101: 103396. DOI: 10.1016/j.ijnurstu.2019.103396
- Sawicki OA, Mueller A, Klaaßen-Mielke R, Glushan A, Gerlach FM, Beyer M, et al. Strong and sustainable primary healthcare is associated with a lower risk of hospitalization in high risk patients. Scientific Reports. 2021; 11(1): 4349. DOI: 10.1038/s41598-021-83962-y
- Wensing M, Szecsenyi J, Laux G. Continuity in general practice and hospitalization patterns: an observational study. BMC Family Practice. 2021; 22(1): 21. DOI: 10.1186/s12875-020-01361-0
- van Loenen T, van den Berg MJ, Westert GP, Faber MJ. Organizational aspects of primary care related to avoidable hospitalization: a systematic review. Family practice. 2014; 31(5): 502–16. DOI: 10.1093/fampra/cmu053
- Huntley A, Lasserson D, Wye L, Morris R, Checkland K, England H, et al. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ Open. 2014; 4(5):
e004746 . DOI: 10.1136/bmjopen-2013-004746 - van Walraven C, Taljaard M, Etchells E, Bell CM, Stiell IG, Zarnke K, Forster AJ. The independent association of provider and information continuity on outcomes after hospital discharge: Implications for hospitalists. Journal of hospital medicine. 2010; 5(7): 398–405. DOI: 10.1002/jhm.716
- Leppert MH, Sillau S, Lindrooth RC, Poisson SN, Campbell JD, Simpson JR. Relationship between early follow-up and readmission within 30 and 90 days after ischemic stroke. Neurology. 2020; 94(12): e1249–e1258. DOI: 10.1212/WNL.0000000000009135
- Bricard D, Or Z. Impact of early primary care follow-up after discharge on hospital readmissions. The European journal of health economics: HEPAC: health economics in prevention and care. 2019; 20(4): 611–23. DOI: 10.1007/s10198-018-1022-y
- Saluja S, Hochman M, Bourgoin A, Maxwell J. Primary Care: the New Frontier for Reducing Readmissions. Journal of General Internal Medicine. 2019; 34(12): 2894–7. DOI: 10.1007/s11606-019-05428-2
- Spencer RA, Singh Punia H. A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital. Patient education and counseling. 2021; 104(7): 1681–703. DOI: 10.1016/j.pec.2020.12.010
- Spivack SB, DeWalt D, Oberlander J, Trogdon J, Shah N, Meara E, et al. The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates. Journal of General Internal Medicine. 2022; 37(12): 3005–12. DOI: 10.1007/s11606-021-07005-y
- Groenewegen PP, Dourgnon P, Greß S, Jurgutis A, Willems S. Strengthening weak primary care systems: steps towards stronger primary care in selected Western and Eastern European countries. Health policy (Amsterdam, Netherlands). 2013; 113(1–2): 170–9. DOI: 10.1016/j.healthpol.2013.05.024
- Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health affairs (Project Hope). 2013; 32(4): 686–94. DOI: 10.1377/hlthaff.2012.1242
DOI: https://doi.org/10.5334/ijic.6534 | Journal eISSN: 1568-4156
Language: English
Submitted on: Feb 28, 2022
Accepted on: Jan 17, 2023
Published on: Jan 27, 2023
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
© 2023 Johanna Forstner, Maximilian Pilz, Cornelia Straßner, Aline Weis, Nicola Litke, Lorenz Uhlmann, Frank Peters-Klimm, Frank Aluttis, Annika Baldauf, Marion Kiel, Markus Qreini, Petra Kaufmann-Kolle, Janina Schubert-Haack, Nadja El-Kurd, Katrin Tomaschko-Ubeländer, Sarah Treffert, Ronja Rück, Bärbel Handlos, Gökce Karakas, Michel Wensing, Joachim Szecsenyi, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.