Tailored Post-Hospital Visits Lower Risk of Readmission for Medicare Advantage Patients

PASADENA, Calif. —Medicare Advantage patients who had tailored post-hospital visits with primary care clinicians, known as POSH visits, were less likely to experience hospital readmission than those who did not have an outpatient visit, according to a Kaiser Permanente study published today in JAMA Internal Medicine.

Tailored POSH visits are scheduled for the patient while he or she is still in the hospital and focus on following up on treatment plans after discharge. In comparison, regular primary care clinician outpatient visits may focus on routine care and not cover specific issues related to a patient’s recent hospitalization.

Researchers found that Medicare Advantage patients who had one or more outpatient visits with primary care clinicians within 7 days of being discharged from the hospital to their homes were 12 to 24 percent less likely to experience hospital readmission than those who did not have an outpatient visit. And patients who had a POSH visit were 28 percent less likely to experience hospital readmission compared to those completing any other type of outpatient visit.

“While other studies had mixed results regarding the effectiveness of post-hospitalization visits, our study highlights the value of both routine and more tailored POSH visits in ensuring continuity of care once a patient transitions from hospital to home,” said Ernest Shen, PhD, research scientist biostatistician at the Kaiser Permanente Southern California Department of Research & Evaluation. “Although any primary care clinician outpatient visit appeared to reduce readmission risk compared to no outpatient visit, the POSH visit provides the added benefit of the care team being alerted to, and therefore better prepared to address, patients’ post-discharge needs.”

The study examined the electronic health records of more than 71,000 Medicare Advantage patients who were discharged to home from Kaiser Permanente hospitals between January 1, 2011 and December 31, 2014. To address the potential bias that patients who had an outpatient visit may have been less sick than those who did not, the researchers accounted for several important factors, including severity of the condition during hospitalization, underlying illnesses, and functional status.

Other authors of the study include Brian Mittman, PhD, and Huong Q. Nguyen, PhD, RN, from the Kaiser Permanente Southern California Department of Research & Evaluation; Sandra Y. Koyama, MD, Dan N. Huynh, MD, Heather L. Watson, MBA, and Michael H. Kanter, MD, from Clinical Operations, Kaiser Permanente Southern California.

This study was partially supported through a collaboration with Project ACHIEVE, a Patient-Centered Outcomes Research Institute (PCORI) awardee (TC-1403-14049), and internal operational funding from Kaiser Permanente Southern California.

About the Kaiser Permanente Southern California Department of Research & Evaluation
The Department of Research & Evaluation conducts high-quality, innovative research into disease etiology, prevention, treatment and care delivery. Investigators conduct epidemiologic research, health services research, biostatistics research, and behavioral research as well as clinical trials. Major areas of study include chronic disease, infectious disease, cancer, drug safety and effectiveness, and maternal and child health. Headquartered in Pasadena, California, the department focuses on translating research to practice quickly to benefit the health and lives of Kaiser Permanente Southern California members and the general public. Visit kp.org/research.

About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 10.6 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.