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A successful hospital-based disease management program to reduce admissions among patients with multiple chronic illnesses

Ariel Linden, Marco Bonollo, Kaylene Fiddes


Objectives: To examine the effect of a hospital-based disease management program in reducing monthly hospital admission rates among patients with multiple chronic illnesses.

Design: Interrupted time series analysis.

Setting: A public hospital system comprised of three campuses in suburban Melbourne, Australia.

Participants: 2,341 patients with three or more chronic illnesses enrolled in a hospital-based disease management program upon discharge.

Intervention: Prior to hospital discharge, an inpatient coordinator refers eligible patients to the disease management unit (DMU). A DMU care coordinator invites patients to enroll and immediately schedules a comprehensive hospital-based outpatient clinic visit. The clinic utilizes a patient-centered team approach including a physician trained in multi-specialty care, a pharmacist, and a DMU nurse. Additional clinic visits are scheduled as needed. Between clinic visits, patients receive continued intensive contact with the DMU team, home visits by a pharmacist if necessary and optional patient education classes. The DMU liaises with the patient’s general practitioner throughout the program until the patient is stable.

Measurement: Admissions per 1,000 patients per month (PTPM), evaluated 50 months before and 50 months after enrollment in the DMU program.

Results: During the 50 month period pre-intervention period, admissions trended significantly upward at a rate of 2.43 admissions PTPM (95% confidence interval = 1.47, 3.38). Admissions PTPM during the 50-month period after enrollment trended significantly downward at a rate of 3.54 admissions PTPM (95% confidence interval = -4.71, -2.37). 

Conclusion: A comprehensive hospital-based disease management program successfully reduced monthly admissions for complex chronically ill patients during the 50 months following enrollment in the program compared to the prior 50 months. Contrary to many recent disease management evaluations, these findings suggest that it is possible to design a program to effectively reduce admissions, the largest cost driver in a chronically ill population, but that a person-centered closed-loop system involving both inpatient and outpatient services is likely required.

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