Providing Team Based Care After Hospital Discharge Did Not Reduce Readmission Rates Or Deaths



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INTRO: After patients leave the hospital, many can experience complications and may even require readmission. In the United States, hospitals can face financial penalties if readmission rates for Medicare patients are too high. A new study examined whether providing elements of care that patients receive while in the hospital, after they are discharged, would help to reduce readmission rates and deaths. Catherine Dolf explains in this week’s JAMA Report. B-ROLL Jean cooking at stove JEAN STAGG HAS BEEN IN AND OUT OF THE HOSPITAL ABOUT SEVEN TIMES THIS YEAR. SOT/FULL Jean Stagg - Virtual Ward Patient Super@:05 Runs:06 “I was out like one day and I was back in again and I was out a couple of days, I was back in again.” SOT/FULL Irfan Dhalla, M.D., M.Sc., - St. Michael’s Hospital, Toronto Super@:10 Runs:05 “A lot of patients run into problems after they leave the hospital. It can be a very confusing time.” B-ROLL Dr. Dhalla walking into office, sitting at table with co-workers, gurney being pushed down hall, women sitting at table DR. IRFAN (Ear-Fahn) DHALLA (Dah-Lah) FROM ST. MICHAEL’S HOSPITAL IN TORONTO AND CO-AUTHORS EXAMINED WHETHER OR NOT A NEW MODEL OF CARE KNOWN AS THE VIRTUAL WARD WOULD HELP KEEP PATIENTS FROM BEING READMITTED. THIS IS THE VIRTUAL WARD AT WOMEN’S COLLEGE HOSPITAL IN TORONTO. NATSO/FULL Runs: 05 “…so that we know sort of prognosis and then what my transition plan will be…” B-ROLL Various shots of women at table THE TEAM MEETS DAILY TO DISCUSS PATIENTS BEING DISCHARGED AND PATIENTS WHO ARE ALREADY BACK HOME. SOT/FULL Irfan Dhalla, M.D., M.Sc., - St. Michael’s Hospital, Toronto Super@ :40 Runs:08 (Video covering middle of bite: woman writing notes) “The idea was to produce a sort of customized care plan that would be exactly right for that particular patient.” B-ROLL Patient in wheelchair leaving hospital, pan to woman on phone NEARLY TWO THOUSAND DISCHARGED PATIENTS WERE FOLLOWED OVER THE COURSE OF THE FOUR YEAR STUDY. HALF THE PATIENTS RECEIVED CARE FROM THE VIRTUAL WARD THAT INCLUDED, CONTACT BY PHONE… NATSO/FULL Runs:03 “…how have things been going since you’ve come home from the hospital?...” B-ROLL Doctor looking at computer and records, Jean sitting at table talking with health care worker …COORDINATING CARE WITH A PATIENT’S PRIMARY CARE DOCTOR ALONG WITH CLINIC AND HOME VISITS. NATSO/FULL Runs: 05 “…where do you think you’d put your overall health on that scale from one to 100 today…I’d say maybe 75…” SOT/FULL Irfan Dhalla, M.D., M.Sc., - St. Michael’s Hospital, Toronto Super@ 1:10 Runs:05 “We didn’t reduce readmissions or deaths after discharge nearly as much as we had hoped.” GXF FULL JAMA COVER THE STUDY APPEARS IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. SOT/FULL Irfan Dhalla, M.D., M.Sc., - St. Michael’s Hospital, Toronto Super@1:19 Runs:10 (Video covering 2nd half of bite: patient leaving the hospital) “We really didn’t see a significant reduction at 30 days after discharge, 90 days after discharge, six months or one year after discharge.” B-ROLL Patient in hospital bed MOST OF THE PATIENTS IN THE STUDY WERE OLDER AND AT HIGHER RISK FOR READMISSION. NATSO/FULL Runs:01 “…want me to do that for a little while…” B-ROLL Jean in kitchen with sister JEAN IS FEELING BETTER AND IS NOW LIVING WITH HER SISTER AND THEIR DOG, RUSTY. NATSO/FULL Runs:02 “…get the baby…give me the baby…” B-ROLL Jean playing with Rusty SHE SAYS HER EXPERIENCE WITH THE VIRTUAL WARD WAS A GOOD ONE. SOT/FULL Jean Stagg - Virtual Ward Patient Super@1:44 Runs:05 “It makes you feel like somebody cares, really cares for you.” B-ROLL Jean on couch with Rusty CATHERINE DOLF, THE JAMA REPORT.
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