An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial

Screening and Referral for Social Needs Among Veterans: A Randomized Controlled Trial

BACKGROUND

Healthcare-based social need screening and referral (S&R) among adult populations has produced equivocal results regarding social need resource connection.

OBJECTIVE

Assess the efficacy of S&R on resource connection (primary outcome) and unmet need reduction (secondary outcome).

DESIGN

Intention-to-treat randomized controlled trial. Analyses adjusted for demographics (e.g., age, race), comorbidity (Elixhauser), and VA priority group (PG).

PARTICIPANTS

Veterans with and at-risk for cardiovascular disease and one of more (hereafter " ≥ 1") social needs receiving healthcare at one of three Veterans Healthcare Administration (VHA) medical facilities.

INTERVENTION

Study arms represented referral strategies of varying intensity. Arm 1 (control) received generic resource information; Arm 2 (low intensity) received generic and tailored resource information; Arm 3 (high intensity) received all the above plus social work navigation assistance.

MAIN MEASURES

Post index surveys at 2-months assessed resource connection (connection to ≥ 1 new resources) and 6-months assessed need reduction (≥ 1 needs at the index screen no longer identified).

KEY RESULTS

A total of 479 Veterans were randomized: 50% were minoritized Veterans, mean age was 64, and 91% were male. Arm 3 was associated with greater resource connection but differences across study arms were not statistically significant. For example, compared to the control arm, participants in Arm 3 had higher but non-statistically significant odds of connecting to ≥ 1 resources (OR = 1.60, CI [.96, 2.67]).

CONCLUSIONS

Among VHA-enrolled Veterans, a high-intensity S&R intervention was associated with a non-statistically significant increase in connection to social need resources. Further study needed to establish S&R efficacy.

TRIAL REGISTRATION

NCT04977583.

Outpatient Follow-Up Visits to Reduce 30-Day All-Cause Readmissions for Heart Failure, COPD, Myocardial Infarction, and Stroke: A Systematic Review and Meta-Analysis

Introduction

Hospital readmissions is an important public health problem that US hospitals are responsible for reducing. One strategy for preventing readmissions is to schedule an outpatient follow-up visit before discharge. The objective of this study was to determine whether outpatient follow-up visits are an effective method to reduce 30-day all-cause readmissions for patients discharged from US hospitals with heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), or stroke.

Methods

We conducted a systematic review and meta-analysis to identify relevant articles published from 2013 through 2023. We searched PubMed, CINAHL, and Cochrane. Eligible studies were those that assessed the effect of postdischarge outpatient follow-up visits on 30-day all-cause readmission. We used random effect meta-analyses to generate pooled adjusted effect estimates and 95% CIs.

Results

We initially identified 2,256 articles. Of these, 32 articles underwent full-text review and 15 met inclusion criteria. Seven studies addressed heart failure, 3 COPD, 2 AMI, and 3 stroke. Ten articles provided sufficient information for meta-analysis. The pooled adjusted effect measure was 0.79 (95% CI, 0.69-0.91), indicating that outpatient follow-up visits were associated with a 21% lower risk of readmission. However, we found a high degree of between-study heterogeneity (Q = 122.78; P < .001; I2 = 92.7%). Subgroup analyses indicated that study quality, disease condition, and particularly whether a time-dependent analysis method was used, explained much of the heterogeneity.

Conclusion

Outpatient follow-up visits are a potentially effective way to reduce 30-day all-cause readmissions for patients discharged with heart failure or stroke, but evidence of benefit was lacking for COPD and we found no studies for assessing AMI. Our results emphasize the importance of study quality.

A Randomized Controlled Trial Testing the Effects of a Social Needs Navigation Intervention on Health Outcomes and Healthcare Utilization among Medicaid Members with Type 2 Diabetes

Health systems are increasingly assessing and addressing social needs with referrals to community resources. The objective of this randomized controlled trial was to randomize adult Medicaid members with type 2 diabetes to receive usual care (n = 239) or social needs navigation (n = 234) for 6 months and compare HbA1c (primary outcome), quality of life (secondary outcome), and other exploratory outcomes with t-tests and mixed-effects regression. Eligible participants had an HbA1c test in claims in the past 120 days and reported 1+ social needs. Data were collected from November 2019 to July 2023. Surveys were completed at baseline and at 3-, 6-, and 12-month follow-up. Health plan data included care management records and medical and pharmacy claims. The sample was from Louisiana, USA, M = 51.6 (SD = 9.5) years old, 76.1% female, 66.5% Black, 29.4% White, and 3.0% Hispanic. By design, more navigation (91.5%) vs. usual care (6.7%) participants had a care plan. Social needs persisted for both groups. No group differences in HbA1c tests and values were observed, though the large amount of missing HbA1c lab values reduced statistical power. No group differences were observed for other outcomes. Proactively eliciting and attempting to provide referrals and resources for social needs did not demonstrate significant health benefits or decrease healthcare utilization in this sample.

Evaluating Intensity, Complexity, and Potential for Causal Inference in Social Needs Interventions: A Review of a Scoping Review

Importance

Interventions that address needs such as low income, housing instability, and safety are increasingly appearing in the health care sector as part of multifaceted efforts to improve health and health equity, but evidence relevant to scaling these social needs interventions is limited.

Objective

To summarize the intensity and complexity of social needs interventions included in randomized clinical trials (RCTs) and assess whether these RCTs were designed to measure the causal effects of intervention components on behavioral, health, or health care utilization outcomes.

Evidence Review

This review of a scoping review was based on a Patient-Centered Outcomes Research Institute-funded evidence map of English-language US-based RCTs of social needs interventions published between January 1, 1995, and April 6, 2023. Studies were assessed for features related to intensity (defined using modal values as providing as-needed interaction, 8 participant contacts or more, contacts occurring every 2 weeks or more often, encounters of 30 minutes or longer, contacts over 6 months or longer, or home visits), complexity (defined as addressing multiple social needs, having dedicated staff, involving multiple intervention components or practitioners, aiming to change multiple participant behaviors [knowledge, action, or practice], requiring or providing resources or active assistance with resources, and permitting tailoring), and the ability to assess causal inferences of components (assessing interventions, comparators, and context).

Findings

This review of a scoping review of social needs interventions identified 77 RCTs in 93 publications with a total of 135 690 participants. Most articles (68 RCTs [88%]) reported 1 or more features of high intensity. All studies reported 1 or more features indicative of high complexity. Because most studies compared usual care with multicomponent interventions that were moderately or highly dependent on context and individual factors, their designs permitted causal inferences about overall effectiveness but not about individual components.

Conclusions and Relevance

Social needs interventions are complex, intense, and include multiple components. Our findings suggest that RCTs of these interventions address overall intervention effectiveness but are rarely designed to distinguish the causal effects of specific components despite being resource intensive. Future studies with hybrid effectiveness-implementation and sequential designs, and more standardized reporting of intervention intensity and complexity could help stakeholders assess the return on investment of these interventions.

The Camden Coalition Care Management Program Improved Intermediate Care Coordination: A Randomized Controlled Trial

When a randomized evaluation finds null results, it is important to understand why. We investigated two very different explanations for the finding from a randomized evaluation that the Camden Coalition's influential care management program-which targeted high-use, high-need patients in Camden, New Jersey-did not reduce hospital readmissions. One explanation is that the program's underlying theory of change was not right, meaning that intensive care coordination may have been insufficient to change patient outcomes. Another explanation is a failure of implementation, suggesting that the program may have failed to achieve its goals but could have succeeded if it had been implemented with greater fidelity. To test these two explanations, we linked study participants to Medicaid data, which covered 561 (70 percent) of the original 800 participants, to examine the program's impact on facilitating postdischarge ambulatory care-a key element of care coordination. We found that the program increased ambulatory visits by 15 percentage points after fourteen days postdischarge, driven by an increase in primary care; these effects persisted through 365 days. These results suggest that care coordination alone may be insufficient to reduce readmissions for patients with high rates of hospital admissions and medically and socially complex conditions.

Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs

Although patient centredness is part of providing high-quality health care, little is known about the effectiveness of care transition interventions that involve patients and their families on readmissions to the hospital or emergency visits post-discharge. This systematic review (SR) aimed to examine the evidence on patient- and family-centred (PFC) care transition interventions and evaluate their effectiveness on adults' hospital readmissions and emergency department (ED) visits after discharge. Searches of Medline, CINAHL, and Embase databases were conducted from the earliest available online year of indexing up to and including 14 March 2021. The studies included: (i) were about care transitions (hospital to home) of ≥18-year-old patients; (ii) had components of patient-centred care and care transition frameworks; (iii) reported on one or more outcomes were among hospital readmissions and ED visits after discharge; and (iv) were cluster-, pilot- or randomized-controlled trials published in English or French. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers. A narrative synthesis was performed, and pooled odd ratios, standardized mean differences, and mean differences were calculated using a random-effects meta-analysis. Of the 10,021 citations screened, 50 trials were included in the SR and 44 were included in the meta-analyses. Care transition intervention types included health assessment, symptom and disease management, medication reconciliation, discharge planning, risk management, complication detection, and emotional support. Results showed that PFC care transition interventions significantly reduced the risk of hospital readmission rates compared to usual care [incident rate ratio (IRR), 0.86; 95% confidence interval (CI), 0.75-0.98; I2 = 73%] regardless of time elapsed since discharge. However, these same interventions had minimal impact on the risk of ED visit rates compared to usual care group regardless of time passed after discharge (IRR, 1.00; 95% CI, 0.85-1.18; I2 = 29%). PFC care transition interventions containing a greater number of patient-centred care (IRR, 0.73; 95% CI, 0.57-0.94; I2 = 59%) and care transition components (IRR, 0.76; 95% CI, 0.64-0.91; I2 = 4%) significantly decreased the risk of patients being readmitted. However, these interventions did not significantly increase the risk of patients visiting the ED after discharge (IRR, 1.54; CI 95%, 0.91-2.61). Future interventions should focus on patients' and families' values, beliefs, needs, preferences, race, age, gender, and social determinants of health to improve the quality of adults' care transitions.

Effectiveness of Social Needs Screening and Interventions in Clinical Settings on Utilization, Cost, and Clinical Outcomes: A Systematic Review

Objective:

This systematic review examined and synthesized peer-reviewed research studies that reported the process of integrating social determinants of health (SDOH) or social needs screening into electronic health records (EHRs) and the intervention effects in the United States.

Methods:

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, a systematic search of Scopus, Web of Science Core Collection, MEDLINE, and Cochrane Central Register of Clinical Trials was performed. English language peer-reviewed studies that reported the process of integrating SDOH or social needs screening into EHRs within the U.S. health systems and published between January 2015 and December 2021 were included. The review focused on process measures, social needs changes, health outcomes, and health care cost and utilization.

Results:

In total, 28 studies were included, and half were randomized controlled trials. The majority of the studies targeted multiple SDOH domains. The interventions vary by the levels of intensity of their approaches and heterogeneities in outcome measures. Most studies (82%, n=23) reported the findings related to the process measures, and nearly half (43%, n=12) reported outcomes related to social needs. By contrast, only 39% (n=11) and 32% (n=9) of the studies reported health outcomes and impact on health care cost and utilization, respectively. Findings on patients' social needs change demonstrated improved access to resources. However, findings were mixed on intervention effects on health and health care cost and utilization. We also identified gaps in implementation challenges to be overcome.

Conclusion:

Our review supports the current policy efforts to increase U.S. health systems' investment toward directly addressing SDOH. While effective interventions can be more complex or resource intensive than an online referral, health care organizations hoping to achieve health equity and improve population health must commit the effort and investment required to achieve this goal.