Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: A Randomized Controlled Trial

BACKGROUND: Emerging evidence from the virtual ward care model showed that multidisciplinary case management are inadequate to reduce readmissions or death for high risk patients. There is consensus that interventions should encompass both pre-hospital discharge and post-discharge transitional care to be effective. Integrated practice units (IPU) had been proposed as an approach of restructuring the organization and work processes of multidisciplinary teams to achieve value in healthcare. Our primary objective is to evaluate if the novel application of the IPU concept to organize a modified virtual ward model incorporating pre-hospital discharge transitional care can reduce readmissions of patients at highest risk for readmission. METHODS: We conducted an open label, assessor blinded randomized controlled trial on patients with one or more unscheduled readmissions in the prior 90 days and LACE score ≥ 10. 840 patients were randomized in 1:1 ratio and blocks of 6 to the intervention program (n = 420) or control (n = 420). Allocation concealment was effected via an off-site telephone service maintained by a hospital administrator. Intervention patients received discharge planning, medication reconciliation, coaching on self-management of chronic diseases using standardized action plans and an individualized care plan complete with written discharge instructions, appointments schedule, medication changes and the contact information of the outpatient VW nurse before discharge. At discharge, care is handed over to the outpatient VW team. Patients were closely monitored in the VW for three months that included a telephone review within 72 hours of discharge, home assessment, regular telephone reviews to identify early complications and early review clinics for patients who destabilize. The VW meet daily to discuss new patients and review care plans for patients. Control patients received standard hospital care that included a standardized patient copy of the hospital discharge summary listing their medical diagnoses and medications; and follow up is arranged with a primary care provider or specialist as considered necessary. The primary outcome was the unplanned readmission rate to any hospital within 30 days of discharge. Secondary outcomes included the unplanned readmission rate, emergency department (ED) attendance rate to any hospital and the probability without readmission or death up to 180 days of discharge. Length of stay and mortality rate at 90-day were compared between the two groups. Outcome data were objectively retrieved from the hospital and National Electronic Health Records by a blinded outcome assessor. FINDINGS: All patients’ outcomes were included in an intention-to-treat analysis. The characteristics of both study groups were similar. Patients in the intervention group had a significant reduction in the number of 30-day readmissions, IRR 0.67 (95% CI, 0.52 to 0.86, p = 0.001) and the number of 30-day emergency department attendances, IRR 0.60 (95% CI, 0.46 to 0.79, p<0.001) compared to those receiving standard hospital care. The effectiveness was sustained at 90 and 180 days. The intervention group utilized 1164 fewer hospital bed days at 90-day post discharge. No adverse events were reported. CONCLUSION: Applying the integrated practice unit concept to the virtual ward program resulted in reduced readmissions in patients who are at highest risk of readmission.