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ForwardWMJ Vol 122 Issue 1: Ambulatory Intensive, Multidisciplinary Telehealth for High-Risk Discharges: Program Development, Implementation, and Early Impact
ABSTRACT
Introduction: Creating and implementing programs aimed at reducing readmissions for high-risk patients is critical to demonstrate quality and avoid financial penalties. Intensive, multidisciplinary interventions providing care to high-risk patients utilizing telehealth have not been explored in the literature. This study seeks to explain the quality improvement process, structure, intervention, lessons learned, and early outcomes of such a program.
Methods: Patients were identified prior to discharge with a multicomponent risk score. The enrolled population was managed intensively for 30 days after discharge through a suite of services, including weekly video visits with an advanced practice provider, pharmacist, and home nurse; regular lab monitoring; telemonitoring of vital signs; and intensive home health visits. The process was iterative, including a successful pilot phase followed by an expanded health system-wide intervention analyzing multiple outcomes, including satisfaction with video visits, self-rated improvement in health, and readmissions compared to matched populations.
Results: The expanded program resulted in improvements in self-reported health (68.9% reported health was some or greatly improved) and high satisfaction with video visits (89% rated satisfaction with video visits 8-10 on a scale of 0-10). Thirty-day readmissions were reduced compared to individuals with similar readmission risk scores discharged from the same hospital (18.3% vs 26.4%) and individuals who declined to participate in the program (18.3% vs 31.1%).
Conclusions: This novel model using telehealth to provide intensive, multidisciplinary care to high-risk patients has been successfully developed and deployed. Key areas for growth and exploration include developing an intervention that captures a greater percentage of discharged high-risk patients, including non-homebound patients, improving the electronic interface with home health care, and reducing costs while serving more patients. Data show that the intervention results in high patient satisfaction and improvements in self-reported health, with preliminary data showing reductions in readmission rates.
Intended Audience
The target audience for this journal-based activity is healthcare providers caring for the people and communities of Wisconsin and beyond.
Learning Objectives
As a result of this journal-based activity, learners, as members of the healthcare team, will be able to:
- Explain an intervention designed to provide multidisciplinary care to high-risk patients utilizing telehealth that was reported in the article .
- Evaluate the intervention outcomes, including satisfaction with video visits, self-rated improvement in health, and readmissions compared to matched populations.
- Discuss how this novel telehealth approach can be used in the learner’s healthcare setting.
FACULTY DISCLOSURE
It is the policy of the University of Wisconsin–Madison Interprofessional Continuing Education Partnership (ICEP) to identify, mitigate and disclose all relevant financial relationships with ineligible companies* held by the speakers/presenters, authors, planners, and other persons who may influence content of this accredited continuing education (CE). In addition, speakers, presenters and authors must disclose any planned discussion of unlabeled/unapproved uses of drugs or devices during their presentation.
For this accredited continuing education activity all relevant financial relationships have been mitigated and detailed disclosures are listed below.
| Name of Individual | Individual's Role in Activity | Financial Relationship Disclosure | Discussion of |
| Brian Hilgeman, MD | Author | No relevant relationships with ineligible companies to disclose | No |
| Geoffrey Lamb, MD | Author | No relevant relationships with ineligible companies to disclose | No |
| Quratul Aziz, MD | Reviewer | No relevant relationships with ineligible companies to disclose | No |
| Thomas Hahn, MD | Reviewer | No relevant relationships with ineligible companies to disclose | No |
| Fahad Aziz, MD | Editor | No relevant relationships with ineligible companies to disclose | No |
| David Dwyer, PhD, RN, NE-BC | Reviewer | No relevant relationships with ineligible companies to disclose | No |
| Cassie Meffert, PA | Reviewer | No relevant relationships with ineligible companies to disclose | No |
| Shezad Baloch | Accreditation Specialist | No relevant relationships with ineligible companies to disclose | No |
*Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on, patients.
The ACCME does not consider providers of clinical services directly to patients to be ineligible companies.
Accreditation
Accreditation Statement
 | In support of improving patient care, this activity has been planned and implemented by the University of Wisconsin–Madison ICEP and the Wisconsin Medical Journal. The University of Wisconsin–Madison ICEP is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. |
Credit Designation Statements
American Medical Association (AMA)
The University of Wisconsin–Madison ICEP designates this journal-based CE activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
American Nurses Credentialing Center (ANCC)
The University of Wisconsin–Madison ICEP designates this journal-based CE activity for a maximum of 1.0 ANCC contact hours .
 | The University of Wisconsin–Madison ICEP has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1 AAPA Category 1 CME credits. Approval is valid until 02/19/2025. PAs should only claim credit commensurate with the extent of their participation. |
Continuing Education Units
The University of Wisconsin–Madison ICEP, as a member of the University Professional & Continuing Education Association (UPCEA), authorizes this program for 0.1 continuing education units (CEUs) or 1 hour.
Available Credit
- 1.00 AAPA Category 1 CME
- 1.00 AMA PRA Category 1 Credit™
- 1.00 ANCC Contact Hours
- 1.00 University of Wisconsin–Madison Continuing Education Hours
- 1.00 Approved for AMA PRA Category 1 Credit™
Registration for this activity can only be completed through the ICEP Learning Portal. Attendee registrations made through any other sites cannot be honored. UW-Madison ICEP is not able to refund fees paid through unaffiliated registration sites, such as eMedEvents.com, MedConfWorld.com, EventEgg.com, and 10times.com. Please report any unauthorized websites or solicitations for registrations to help@icep.wisc.edu.
Accessibility
The University of Wisconsin provides equal opportunities in employment and programming, including Title IX requirements. The University of Wisconsin fully complies with the legal requirements of the ADA and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please notify us at help@icep.wisc.edu
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