Running head: REDUSING READMISSIONS

Comparing the effect of Transitional Virtual Visits in Reducing Readmission Rates
Adriana C. Furletti, RN, BSN, CHPN
Arizona State University Student

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Acknowledgements

Jennifer Mensik, PhD, RN, NEA-BC, FAAN
Arizona State University Project Mentor

Gobi Paramanandam, MD
Arizona Palliative Home Care

Barbara Volk-Craft
Hospice of the Valley

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Abstract

Hospital readmissions for palliative care patients are costly for patients, families, insurance
providers, and palliative care organizations. The evidence shows that integrating virtual visits into
palliative care is an innovative way to reduce hospital readmissions, preserve costs, and reduce
geographical barriers. The purpose of this article is to evaluate how well transitional care virtual
visits reduce future hospital readmissions for palliative care patients when compared to usual care
of in-home nurse visits. Palliative care patients from a large palliative company in Arizona, who
received a transitional care, post hospital discharge, virtual visit with traditional model care
(intervention) were compared to randomly selected traditional model care patients (control). Data
was collected through a retrospective chart review at 30 and 60 days post hospital discharge to
evaluate for hospital readmissions and avoided readmissions. The Fishers Exact test was used to
compare the results of the two groups to each other. There was no significant difference between
the two groups. Virtual visits have an added cost to the agency without decreasing the risk of
readmission. Implications for practice are to continue offering transitional care in-home nurse
visits. Future research should evaluate if using virtual visits justify the increased costs of use.

Keywords: hospital readmissions; palliative care; virtual visits

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Comparing the effect of Transitional Virtual Visits in Reducing Readmission Rates
The focus of palliative medicine is to maximize a patient’s comfort and quality of life
(QOL) by managing symptoms. Reducing the number of times a patient must go to the hospital
for more aggressive symptom management can impact both QOL and the illness burden while
minimizing cost to both the patient and the healthcare system. Also, many palliative patients are
not able to go to a doctor’s office to see a provider because of the disease related limitations. Most
provider office visits and hospitalizations could be avoided with increased or alternative ways to
access care. The evidence supports that offering a virtual visit (VV) in conjunction with an inhome nurse visit (IHNV) to palliative patients, as part of the transition of care post hospital
discharge, can improve their access to care further reducing the risk for re-hospitalization. The
purpose of this paper is to evaluate the use of VVs to reduce hospital readmissions for palliative
care patients.
Background and Significance
Providing VVs to palliative patients improves their access to care and can help improve
symptom control. Watanabe et al1 found that rural palliative patients expressed decreased anxiety
and increased appetite after participating in a palliative care (PC) program that offered VVs.
Patients reported improved outcomes, increased satisfaction with care, ability to receive care in
location of choice, and prolonged life during participation in a PC program compared to those who
did not receive PC.2 The use of home monitoring and VVs through technology was found to
decrease needs for emergency services, improve management of symptoms, and increase family
member confidence in care when provided with in-home nursing services for PC patients.3 Using
pre-existing technology to provide VVs is feasible, enhances communication and engagement
between patients and providers, and increases patient satisfaction.4 Husebø and Storm5 found that

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VVs in the home complement in-person visits in meeting the complex needs of older adults.
Summerfelt et al6 conducted a study that found that the use of VVs by physicians in conjunction
with home licensed practical nurse visits efficaciously replaced the need for patients to go to the
hospital for treatment of complications of COPD, heart failure, and pneumonia.
The reason PC VVs are offered in conjunction with usual care, which includes in-home
nurse visits, is to prevent readmissions and improve QOL. Cassel et al7 found that proactive
admission to a PC program resulted in lower overall costs to both the patient and the payer, and
decreased the risk of hospital readmission. An inverse proportion of readmission rates compared
to PC utilization indicates that areas that have a higher proportion of palliative agencies see fewer
readmissions.8 Feltner et al9 found that offering transitional care interventions, including homevisiting programs in combination with multidisciplinary heart failure interventions and structured
telephone support, had a high level of significance in reducing readmissions of heart failure
patients.
Participation in a PC program can improve outcomes, increase satisfaction with care, and
enhance QOL for terminally or chronically ill patients. There are steadily increasing numbers of
patients participating in PC. Readmissions to the hospital decrease QOL and increase cost for
patients and payor sources. Offering VVs as part of a transitional process from the hospital to home
PC is a feasible and cost-effective way of improving access to care and reducing the risk of
rehospitalization. Increased activity of PC program in an area, can reduce that areas readmission
rate through use of VVs in collaboration with IHNVs. The clinical significance is that providers
can enhance QOL for patients who have increased care needs and are at higher risk of readmission
to the hospital while also reducing the cost burden of illness for both patients and payors.
Problem Statement

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Palliative care is an important aspect of improving QOL for people faced with a terminal
illness or who have multiple chronic diseases that are difficult to manage. Dumanovsky10 reported
that the U.S. has seen continued steady growth of PC programs throughout the country.
Unfortunately, providers are not always able to provide the care needed by palliative patients due
to barriers. Some of the barriers for access to a PC program include geographic location, confusion
about terminology, mistrust of health care professionals, uncertainty about their prognosis, poor
referrals11, cultural views of PC, and poor staffing of PC agencies.12 Providers can offer care
solutions to palliative patients through the use of technology so patients can remain in their homes.
Palliative patients require frequent access to providers to manage the health concerns and
symptoms related to their life limiting or chronic illnesses. The Worldwide Palliative Care Alliance
(WPCA)13 estimates that about 20.4 million patients need PC as they near end of life. R. Bruckner
reports that Arizona Palliative Home Care (AZPHC) admitted 3,261 patients to palliative care in
2016, with an average daily census of 680 patients (personal communication, February 9, 2017).
“The great majority of adults in need of PC died from cardiovascular diseases (38.5%) and cancer
(34%), followed by chronic respiratory diseases (10.3%), HIV/AIDS (5.7%), and diabetes
(4.5%)”13. Readmission to the hospital can decrease QOL for many patients.
Hospital readmission is a great concern for patients, providers, and insurance companies.
The Health Services Advisory Group14 reports that Arizona had about 25,000 all cause hospital
readmissions of Medicare patients in one year. Hines et al15 state that Medicare had the largest rate
of hospital readmissions within 30 days of discharge in 2011 totaling 55.9% of readmissions
followed by Medicaid’s at a 20.6%, private insurance at 18.6%, and the uninsured are only at 4.9%.
AZPHC reports that they had 220 insurance contracted PC patients that were readmitted to the
hospital within 30 days of hospital discharge in 2016 (R. Brueckner, personal communication,

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February 15, 2017). Hines et al15 state that the most common causes of readmission are congestive
heart failure, septicemia, pneumonia, COPD, cardiac dysrhythmias, UTIs, renal failure, acute MIs,
device and graft complications, and acute CVAs. A total of $41.3 billion was spent on hospital
readmissions within the first 30 days after discharge in 2011.15 Edelman16 states that the most
common factors for hospital readmission are pre-mature discharge from the hospital, failure to
report to outpatient providers, emergency department decision making, and that patients lack
awareness on who to contact after initial hospital discharge.
Modern medicine integrates technology into patient care, including VVs. The American
Academy of Family Physicians17 defines a VV as “an evaluation and management service provided
by a physician or other qualified health professional to an established patient using a web-based
or similar electronic-based communication network for a single patient encounter”. Of the
estimated 50 companies in Arizona that offer telemedicine (TM), only six of them offer hospice
or palliative care services.18 In 2014, there was an estimated 350,000 provider visits to all types of
patients using phone and video, with an expected rise to seven million per year by 2018.19 Iafolla19
found that 74% of Americans said they are comfortable with and would use telemedicine. In 2003,
the National Initiative for Telehealth20 Framework of Guidelines was released to help guide
providers and regulatory organizations in developing policies and procedures utilizing TM.
PICO
The inquiry on palliative patients and hospital readmissions has led to the clinically
relevant PICOT question: For palliative patients discharged from the hospital (P), does offering a
transitional care virtual visit with a provider combined with in-home nursing visits (I) compared
to only providing transitional care in-home nursing visits (C) effect the number of hospital
readmissions within 30 and 60 days of discharge (O).

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Search Sources and Process
An exhaustive literature search was performed to search for higher level of evidence (LOE)
articles that discuss the use of VVs to reduce hospital readmissions for PC patients. The databases
searched include PubMed, CINAHL, Cochrane Library, and ProQuest. The search terms used
included various combinations, using the Boolean connector AND, of palliative, telemedicine,
virtual visits, readmission, and transitional. Additional search limitations included only systematic
reviews (SR) or randomized control trials (RCT). Gray literature was also searched but did not
yield any additional references. There was very little evidence that included all three of the PICO
keywords so most of the evaluated articles only included two of the PICO terms. Exclusion criteria
for all databases included any articles published prior to 2011 except the most recent guidelines,
and any use of TM that did not include video conferencing between patient and provider.
Inclusion criteria included higher LOE such as SRs and RCTs and addressed at least two
of the search terms. The studies were included only if they described the SR or study enough to
allow for reproducibility. Some cohort and qualitative studies were also selected because
randomizing PC patients may not be ethical and PC follows a holistic approach best described
using qualitative measures. A total of 12 studies were retained from the search for evidence. Most
of the studies were systematic reviews (SRs) of randomized control trials (RCTs) that also included
quantitative and qualitative studies. Only one of the retained studies falls outside the inclusion
criteria of being published within the last five years.
Critical Appraisal
Most of the studies did not include a significant description of the demographics of
participants as the focus of the studies was based on PC patients of any type, although chronic
disease did attribute to needing PC in the studies. Each study had a varying degree of desired

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independent variables, dependent variables, and outcomes but every study addressed at least two
sections of the PICO question. Multiple studies used the same evaluation tools increasing the
reliability of the tools. The independent variable and outcome of greatest interest are video
conferencing and hospital readmissions, respectively, which are included in at least half of the
studies.
All the studies shared homogeneity in that all studies focused on care provided in the
patient’s home. The most common interventions are the use of telephone visits (n = 8) followed
by video conferencing (n = 7), and three SRs and one RCT compared telephone visits with video
conferencing. The most common dependent variables across the studies includes cost savings (n =
6), hospital readmissions (n = 5), unmet needs of patients (n = 4), and QOL (n = 4). Four studies
addressed TM and home nurse visits but only one study combined the use of home nurse visits
with video conferencing as the independent variable. The most common outcome reported across
the studies was decreased readmissions (n = 5), cost effectiveness of TM (n = 4), followed by
increased QOL (n = 3), and information needs of PC patients and their caregivers (n = 3).
Evidence Synthesis
A review of the evidence suggests that using telephone interventions or video conferencing
in transitional care can reduce hospital readmissions, lower costs, improve QOL, and address
information needs of PC patients. Most patients, caregivers, and providers feel that TM is both an
acceptable means of providing care to PC patients and is feasible in day to day practice. The most
effective way to minimize the risk of readmissions is to use VVs to enhance the usual care of
IHNVs. In home nursing visits, both individually or combined with TM, were found to reduce
short term readmission and improve QOL but TM superseded in reducing overall cost.
Implementation of VVs requires some coordination within an organization and training for staff

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and patients on use of the video conferencing device. By using VVs during the transitional care
process, patients recently released from the hospital can receive medication reviews, have their
concerns addressed, and can be educated on signs and symptoms to monitor for and how to manage
from the comfort of their home, reducing the risk of readmissions.
Purpose of Project
The purpose of this project is to measure the effectiveness of transitional care VVs
compared to traditional model IHNVs in reducing hospital readmissions for palliative patients and
to measure if VVs are a cost-effective way of reducing readmissions. If found to be valuable in
reducing readmissions and is cost-effective, then transitional care VVs can be implemented as
standard practice. Patients will benefit from improved QOL and decreased costs of care with
decreased hospital readmissions. Providers and Payor sources will benefit from decreased costs
related to hospital readmissions.
Contribution of Theory
The theoretical framework that best describes the interaction between VVs combined with
IHNVs and PC patients is Dorothea Orem’s Self Care Theory. Orem’s theory is a grand nursing
theory that states that self-care behaviors are influenced by the interaction between patients and
their provider’s.21 A patient’s culture, socioeconomic status, environmental factors, and poor selfcare knowledge affect a patient’s ability to maintain and promote health through activities that
reduce symptoms and disease complications.21 The role of the provider, or nursing agency, in
Orem’s self-care theory is to promote self-care by educating patients and their caregivers about
their disease status/needs, plan of self-care, and to encourage increased responsibility of
management of their own health.21 This education can be provided through VVs and IHNVs and
will help enhance self-efficacy of the patients and caregivers to improve their ability to manage

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their care with the tools provided from the provider and the nurse. The patient will be taught to
recognize when symptoms begin, how to manage the symptoms, or to reach out to the PC agency
when symptoms begin instead of allowing the symptoms to become unmanageable if they do not
feel confident in managing symptoms.
Evidence Based Practice Model
The Evidenced based practice (EBP) model that was chosen to guide the project is the
model for change to evidence-based practice by Rosswurm and Larrabee.22 This model provides a
step by step guide that is laid out in a linear form and easy to understand. The problem of PC
readmissions was chosen during the discussion with stakeholders and possible interventions were
discussed including the use of transitional care VVs in combination with IHNVs. The first step to
implementing a VV program to reduce hospital readmissions for PC patients is to discuss
feasibility and implementation procedures with the companies’ stakeholders, to get approval for
the project, and to collect internal evidence about the problem. The organizational stakeholders
involved in the project approval process and implementation include the PC administration staff,
including the organizations institutional review board, education staff, the physician(s)
implementing the VVs, and the physician’s administrative assistant who will be collecting data
and assisting the physician in implementation.
The next step was to perform an exhaustive literature search based on VVs provided during
transitional care for PC pts to reduce readmissions. This step includes evaluating and synthesizing
the evidence while assessing for feasibility in practice. The step after that was to design the data
collection methods to evaluate the effectiveness of VVs after the agency implemented a
transitional care pilot study. Data collected, via chart review, includes the type of visit received by
the patient, PC admission and discharge dates, the number of hospital readmissions and avoided

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hospitalizations that each patient had within 30 and 60 days of hospital discharge, and some
demographics. Finally, the results of the study were statistically analyzed and disseminated to the
stakeholders. If the stakeholders find the results of the project to be valuable, transitional care VVs
will be implemented into practice while continual evaluation of effectiveness is completed.
Project Methods
The Social Behavioral Human Subjects Institutions Review Board (IRB) application, Chart
Review Questionnaire, and supporting documents were submitted to Arizona State University’s
IRB in July 2017 after receiving site approval to implement the project. Corrections were made
based on IRB recommendations until final approval to proceed with the project from the IRB was
received in August 2017. Based on the small number of patients who received a transitional VV
in the originally approved review dates, May thru September 2017, a request for an extension to
add chart reviews for patients discharged in the months of October thru December 2017 was
submitted and approval to continue collecting data was received in November 2017. All charts of
PC patients discharged from the hospital in the months of May thru December 2017 were reviewed
for study appropriateness. All patients who received a transitional care VV combined with an
IHNV were included in the study along with an equal number per month of randomly selected
patients who only received a transitional care IHNV.
The organization where the intervention took place is AZPHC, the largest PC company in
Arizona. This organization uses a collaborative leadership approach that strives to constantly
improve practice with the latest and best innovations along with contributing to evidence based
practice. AZPHC has a strong focus on patient care with the goal to help patients achieve the
highest QOL that is possible by helping to relieve suffering caused by pain and disease related
symptoms through focusing on each patient’s individual needs. Every patient is assigned an

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interdisciplinary team of a physician, registered nurse, social worker, and chaplain to address every
type of physical, psychosocial, and spiritual need that patient may have. Patients receive all the
care they need in the comfort of their own home.
AZPHC was already utilizing VVs for routine follow ups with existing patients who had
seen a provider previously in a face to face setting in their home. The intervention investigated for
the project was to start utilizing VVs, preferably within three days of the patient returning home
from hospital discharge, as part of the transitional care process, and combined with the traditional
model of care of just a transitional IHNV. A chart review was performed within 60 days of hospital
discharge to evaluate if the patient was readmitted to the hospital in 30 and 60 days, if they
remained on PC services the entire 60 days and if not then why, if they received any visits from
AZPHC staff that resulted in an avoided hospitalization within the 60 days, and the number of
prior hospitalizations leading up to the hospitalization resulting in the transitional care visit.
Demographic information collected included age, gender, ethnicity, language, marital status, type
of habitation, and if they lived with a caregiver. The Chart Review Questionnaire was created by
the project director so there are no prior studies to address the tools validity and reliability. In
March 2018, data was entered into SPSS and was analyzed using the Fishers Exact test and
descriptive statistics. The time spent for internal data gathering by AZPHC staff was not
reimbursed by the project and all time used to gather data was by the project director and nonfunded.
Project Results
The transitional visit results of the VV intervention group (n = 14) were compared to the
traditional model IHNV group (n = 15). A 30-day and 60-day chart review showed that there was
no significant difference in reducing hospital readmissions within 30 and 60 days of hospital

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discharge (p = 1.00, Fisher’s Exact test). The average reimbursable rate from Medicare to AZPHC
for a VV is $65 (B. Volk, personal communication, February 5, 2018). Virtual visit patients are no
less likely to experience a hospital readmission but do have added costs since there is no
significance in the reduction of hospital readmissions between the groups.
The groups did show some varying factors that were studied but none of the results were
significant either. About 36% of the VV group (n = 5) compared to about 13% of the IHNV group
(n = 2) spent time in a rehab or skilled nursing facility post hospital and prior to transferring home
where they received the VV. Patient attrition for both groups during the 60-day timeframe were
from transferring off PC service (n = 4), transferring to hospice (n = 5), and death (n = 1). All the
VV patients (n = 7) who experienced readmissions had their first readmission within the first 30
days after hospital discharge. The number of avoided hospitalizations were higher in the first 30
days for 50% of the VV group (n = 7) compared to 26% of the IHNV group (n = 4) but still not
significant (p = 0.203, chi square test). The VV patients had closer to significant results for
readmission cause related to the cause of the initial hospitalization (p = 0.119, Fisher’s Exact test).
Also, the VV group had more prior hospitalizations (𝑥𝑥̅ = 1.64 (std. dev. 1.45)) compared to the
IHNV group (𝑥𝑥̅ = 1 (std. dev. 1.36)), and the IHNV group (n = 8) had 73% more patients that had
no documented prior hospitalizations in the first six months.
Almost 73% of the IHNV group (n = 11) had slightly more patients still on service at the
60-day review point when compared to about 57% of the VV group (n = 8). Length of stay days
of the first hospital readmission was longer for the IHNV group (𝑥𝑥̅ = 5.13(std. dev. 2.99))
compared to the shorter length of stays for the VV group (𝑥𝑥̅ = 3(std. dev. 2.24)). The number of
avoided hospitalizations within the 31 to 60-day timeframe was higher, at about 26%, in the IHNV
group (n = 4), whereas about 7% of the VV group (n = 1) had less avoided hospitalizations.

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Demographically, there was no statistical difference between the groups leading to
homogeneity for both groups. The mean age for the VV group was 76.43 (std. dev. 11.05) with a
median of 77 and the IHNV group had a mean age of 71.93 (std. dev. 17.26) with a median of 74.
The IHNV group had one outlier at the age of 28. Since there was no statistical significance
between the demographics of each group the total of both groups (n = 29) are presented here: male
about 55% (n = 16), Caucasian approximately 66% (n = 19), married about 31% (n = 9), English
speaking is 97% (n = 28), lives in a traditional home about 90% (n = 26), and lives with someone
in the caregiver role nearly 72% (n = 21). The most common primary diagnoses for the VV group,
in descending order, are cancer (43%), COPD (29%), and heart failure (14%) with the most
common top five secondary diagnoses for each patient being hypertension (57%), type 2 diabetes
(36%), heart failure (29%), and an equal amount (21% ea.) for anemia, cancer, heart disease,
hyperlipidemia, and renal disease. The IHNV group had the most common primary diagnoses of
COPD (27%), heart failure (27%), type 2 diabetes (20%) and Cancer (13%) with each patients’
top five most common secondary diagnoses as hypertension (60%), heart disease (40%), renal
disease (40%), type 2 diabetes (33%), depression (27%), and COPD (20%).
Discussion
Although there was no added benefit of reducing hospital readmissions among the VV
group, the literature supports that when VVs are used to supplement IHNVs, there is increased
communication between providers and patients and improved satisfaction with care received.4 The
literature also supports that VV are effective way to improve access to care. The company may
choose to continue to provide transitional care virtual visits, with schedule permitting, to maximize
quality of care and improve communication with patients. The agency may decide that the

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increased cost associated with virtual visits is worth the added benefit found in the literature
associated with VVs.
Strengths of the project included good communication with the project director and the
project site teams. Staff was also receptive, open, and inviting to project implementation and were
willing to do what was necessary for successful project completion. Limitations include that the
level of accuracy of documentation is based on the individual charting, that the agency changed
electronic charting systems in the middle of the project changing the focus from completing VV
with patients to learning a new charting system, and the limited number of virtual visits that were
performed in the eight-month timeframe that data was being collected. Sustainability of a VV
program can be achieved by improving scheduling practices or integrating a full time VV provider
to allow for greater availability of VVs.
Some of the research literature found that using VV to provide care reduces hospital
readmissions but none of the literature addressed transitional care based VVs. Future research can
evaluate why transitional care VV do not affect readmission rates compared to non-transitional
VV that have been shown to reduce readmissions, the other added benefits of VV, and do these
benefits outweigh the cost of the VV. Researchers can focus research on how VV can best be
integrated into PC practice. A similar project can evaluate if VV reduce the number of hospital
readmissions for the hospice and pediatric palliative populations. Additional research can evaluate
how offering VVs to PC patients affects length of stay on PC services.
Conclusion
Hospital readmission for PC patients are costly to patients, payors, and PC agencies, and
can decrease quality of life for the patient. The purpose of this project was to evaluate if transitional
care VVs combined with IHNVs reduced the number of hospital readmissions within 30 and 60

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days after initial hospital discharge and if VVs are a cost-effective way to reduce readmissions. A
comprehensive literature search found 12 articles that support the use of VV in PC. Critical
analysis of the literature showed that benefits of VVs include improved communication, access to
care, and satisfaction with care. Dorothy Orem’s Self Care Theory integrates providers teaching
patients about how to recognize and address symptoms before those symptoms lead to
hospitalization, which can be applied to VVs. Rosswurm and Larrabee’s22 evidence based practice
model guided the project initial from communications with stakeholders to disseminating
evidence. Although, the literature found that VVs have been found to be an effective way at
reducing hospital readmissions for PC patients, the project showed that VVs combined with an
IHNV, during the transitional care phase, are not effective at reducing hospital readmissions within
30 and 60 days. Transitional care VVs have added costs to the agency without reducing
readmissions. Future research should focus on the benefits of VVs and when the most appropriate
time is to provide them.

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