Background: Hospitals face mounting pressure to reduce unplanned utilization amid rising healthcare demands from an aging population. The Case management for At-Risk patients in the Emergency Department (CARED) program is among the first ED transitional care strategies to focus on both frail older adults and Emergency Department (ED) re-attenders to reduce acute hospital utilization. This study aims to evaluate the effectiveness of the CARED program in reducing hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge.
Methods: A retrospective, propensity-matched study was conducted from April 2022 to July 2023 in the ED of Ng Teng Fong General Hospital in Singapore. The CARED program identifies and enrols at-risk patients i.e., frail older adults and patients who re-attend the ED within 30 days of hospital discharge, for a geriatric assessment. This is followed by multidisciplinary team care, discharge planning and right siting of care from the ED to community-based services by ED case managers. The primary outcomes were hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge. Secondary outcomes were cost avoidance and bed occupancy days from reduced acute hospital usage.
Results: Nearest-neighbour 1:1 propensity score matching matched 1,615 intervention group to 1,615 control group. Baseline characteristics of the intervention and control groups did not differ significantly. Difference-in-differences (DID) analyses showed significantly lower 30-day (3.96%; 95% CI 2.71% to 5.23%) and 60-day (6.69%; 95% CI 5.47% to 7.91%) hospital admissions, as well as 30-day (4.89%; 95% CI 3.83% to 5.95%) and 60-day (6.50%; 95% CI 5.28% to 7.72%) ED re-attendances in the intervention group compared to the control group. Additionally, the reduced admission and ED re-attendance rates resulted in 30-day and 60-day inpatient admission costs avoidance ($1,553,548.96 (69.86%); 95% CI $1,525,827.76 to $1,581,270.15; P = 0.006; and $1,400,047.07 (32.56%); 95% CI $1,365,484.79 to $1,434,609.37; P = 0.048 respectively), ED attendance costs avoidance ($25,849.92 (23.70%); 95% CI $25,091.93 to $26,607.89; P = 0.096; and $37,538.39 (18.09%); 95% CI $36,470.27 to $38,606.53; P = 0.086 respectively) and bed occupancy days saved (1,212 days; 95% CI 1,191.80 days to 1,232.20 days; P = 0.003; and 1,267 days; 95% CI 1,242.58 days to 1,291.42 days; P = 0.011 respectively).
Conclusion: CARED program effectively reduced unplanned hospital use within 30- and 60-days post-ED discharge for at-risk patients. It also significantly lowered inpatient admission and ED attendance costs and hospital bed occupancy days, highlighting its potential to improve patient outcomes and reduce healthcare expenses.
Keywords: Case Management, Geriatric Assessment; Emergency Department; Transitional Care; Value-based Care.
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