Telehealth Transitional Care and 30-Day Readmission During the COVID-19 Pandemic

ABSTRACT

Transitional care management (TCM) services after hospital discharge are critical for continuity of care, and the COVID-19 pandemic accelerated the shift to telehealth modes of delivery. This study examined the shift from face-to-face to telehealth care around the start of the pandemic (April-July 2020) compared with the same months in 2019 and 2021 and the corresponding 30-day readmission rates. We compared the rates of face-to-face and telehealth TCM as well as face-to-face and telehealth non-TCM services and observed a dramatic shift to telehealth in 2020 with a slight drop-off in 2021. For TCM services specifically, face-to-face visits made up nearly 90% of visits in 2019, whereas telehealth made up the vast majority in 2020 and 2021 at 97.5% and 84.9%, respectively. Over the same time periods, 30-day readmission rates remained steady at 10% along with no changes in 30-day mortality. Among those who completed TCM visits, 30-day readmission rates remained between 8% and 9% and 30-day mortality remained below 1%. These data indicate that this dramatic systemwide shift from face-to-face to telehealth TCM was not accompanied by concurrent changes in either 30-day readmission or mortality rates. Although the findings may be subject to ecologic bias, the data at hand did not allow for reliable estimation of differences in effects of patient-level service delivery type on readmission risk or mortality due to the extremely low volume of face-to-face visits during the pandemic periods. Future research would be needed to conduct such comparisons.

Am J Manag Care. 2024;30(1):e1-e3. https://doi.org/10.37765/ajmc.2024.89487

Transitional care management (TCM) services after hospital discharge are critical for continuity of care.¹ We previously found that face-to-face TCM provider visits completed within 7 days of hospital discharge were associated with 24% lower risk of 30-day readmission compared with having no TCM visit,² whereas telehealth TCM visits were not associated with lower 30-day readmission risk.³ The COVID-19 pandemic led to broad adoption of telehealth TCM services.⁴ This letter describes the pattern of telehealth TCM services before and during the pandemic and 30-day readmission within an integrated health system.

METHODS

This retrospective cohort study included the first hospitalization for adult nonmaternity medicine patients who were discharged alive with non–COVID-19 conditions from 15 Kaiser Permanente Southern California (KPSC) hospitals between April 1 and July 3 in 2019 (prepandemic), 2020 (early pandemic), and 2021 (late pandemic) to home or home health and remained enrolled in the health plan for at least 30 days post discharge. To align with Healthcare Effectiveness Data and Information Set specifications, patients who were high utilizers were excluded. This study was approved by the KPSC Institutional Review Board.

We classified visits within 7 days post discharge as (1) face-to-face TCM or (2) telehealth TCM (99.8% telephone), similar to our earlier publication.² The primary outcome was all-cause 30-day inpatient or observation readmission, obtained from electronic health records and claims.

Sociodemographic and clinical characteristics (LACE [length of stay, acuity of admission, comorbidities, emergency department use in the previous 6 months] index,⁵ Laboratory-based Acute Physiology Score,⁶ and discharge disposition) were obtained from the electronic health record as described elsewhere.^2,3,7 We report only descriptive statistics on 30-day readmission and mortality rates and patient case mix, stratified by visit type within each study period, due to the very low frequency of face-to-face visits in the early pandemic period.

RESULTS

We observed a similar distribution of patient characteristics across all periods (Table and eAppendix Table [available at ajmc.com]), with patients who had telehealth TCM visits during the early pandemic closely resembling those who had face-to-face visits in the prepandemic period (mean age, 68.6 years; non-White race, 55%). During the early pandemic period, 97.5% of TCM visits were telehealth compared with only 11.4% during the same months in 2019, with less pronounced changes in non-TCM visits (Table and eAppendix Table). Despite the dramatic shifts to telehealth TCM from the pre-pandemic period to the early pandemic period, we did not observe substantive changes in systemwide 30-day readmission rates (8% and 9% total, respectively, and 9% each for telehealth TCM) or 30-day mortality (< 1% total and 1% for telehealth). We observed a similar pattern with the sample stratified by LACE.

DISCUSSION

We found that TCM visits dramatically shifted from face to face to telehealth in 2020 compared with the same months in 2019. Although the late pandemic period showed a small resumption of face-to-face non-TCM visits, the mortality and 30-day readmission rates remained steady. These findings suggest that increased use of telehealth services after hospital discharge was not accompanied by poorer outcomes but can improve access to care. Whereas other studies have found that the higher usage of telehealth TCM visits for White patients compared with Hispanic patients persisted from the prepandemic period to the early pandemic period,8 we found no such differences (10.9% vs 11%, respectively, in 2019 and 97.6% vs 97.2% in 2020).

Limitations of this report include use of descriptive data from one system, the inability to completely account for the impact of shelter-in-place orders on health care utilization, and the risk of ecological bias or confounding by indication due to some patients being unable to present for a face-to-face visit. Although we had individual-level data to address these last concerns, estimates were unreliable due to the disparate distribution of TCM visit modalities across the study periods.

Author Affiliations: Department of Research & Evaluation, Kaiser Permanente Southern California (ES, JSL, HQN), Pasadena, CA; Kaiser Permanente Los Angeles Medical Center (CWH), Los Angeles, CA; Regional Clinical Operations, Kaiser Permanente Southern California (DNH), Pasadena, CA.

Source of Funding: None.

Author Disclosures: Dr Nguyen has received grants from the National Institutes of Health (NIH) and Patient-Centered Outcomes Research Institute and has grants pending from NIH. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ES, DNH, HQN); acquisition of data (CWH, JSL); analysis and interpretation of data (ES, CWH, DNH, JSL, HQN); drafting of the manuscript (ES, JSL, HQN); critical revision of the manuscript for important intellectual content (ES, CWH, HQN); statistical analysis (ES); obtaining funding (HQN); administrative, technical, or logistic support (DNH); and supervision (ES, HQN).

Address Correspondence to: Ernest Shen, PhD, Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA 91101. Email: Ernest.Shen@kp.org.

REFERENCES

1. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528. doi:10.7326/0003-4819-155-8-201110180-00008

2. Shen E, Koyama SY, Huynh DN, et al. Association of a dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a Medicare Advantage population. JAMA Intern Med. 2017;177(1):132-135. doi:10.1001/jamainternmed.2016.7061

3. Nguyen HQ, Baecker A, Ho T, et al. Association between post-hospital clinic and telephone follow-up provider visits with 30-day readmission risk in an integrated health system. BMC Health Serv Res. 2021;21(1):826. doi:10.1186/s12913-021-06848-9

4. Anderson TS, O’Donoghue AL, Dechen T, Herzig SJ, Stevens JP. Trends in telehealth and in-person transitional care management visits during the COVID-19 pandemic. J Am Geriatr Soc. 2021;69(10):2745-2751. doi:10.1111/jgs.17329

5. van Walraven C, Dhalla IA, Bell C, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182(6):551-557. doi:10.1503/cmaj.091117

6. Escobar GJ, Gardner MN, Greene JD, Draper D, Kipnis P. Risk-adjusting hospital mortality using a comprehensive electronic record in an integrated health care delivery system. Med Care. 2013;51(5):446-453. doi:10.1097/MLR.0b013e3182881c8e

7. Shen E, Rozema EJ, Haupt EC, et al; HomePal Research Group. Assessing the concurrent validity of days alive and at home metric. J Am Geriatr Soc. 2022;70(9):2630-2637. doi:10.1111/jgs.17506

8. White-Williams C, Liu X, Shang D, Santiago J. Use of telehealth among racial and ethnic minority groups in the United States before and during the COVID-19 pandemic. Public Health Rep. 2023;138(1):149-156. doi:10.1177/00333549221123575