To cite this abstract:Moraghebi, P; Kasmai, P; Shunmugaraja, S; Kwa, R; Nguyen, L . IMPACT OF POST-HOSPITALIZATION FOLLOW-UP IN A TRANSITIONAL MEDICAL CLINIC ON REDUCING 30-DAY READMISSIONS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 257. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/impact-of-post-hospitalization-follow-up-in-a-transitional-medical-clinic-on-reducing-30-day-readmissions/. Accessed April 4, 2020.
Background: According to Medicare Payment Advisory Commission, about 75% of hospital readmissions are potentially preventable, representing an estimated $12 billion in Medicare spending. Prompt follow-up of hospital patients before primary care and subspecialist appointment may decrease readmissions.Methods: This is a prospective single-site cohort study.We developed a Transitional Medical Clinic (TMC) at Mission Hospital (Mission Viejo, CA) to follow up hospital patients within 1 week of discharge, and collected data to determine if it would decrease readmissions. Readmission is defined as a subsequent inpatient hospital admission within 30-days. We followed 181 patients, mean age 75 years old, at the TMC within one week post hospital discharge from January to June 2016. Criteria for TMC referral included patients with Medicare, HMO or PPO insurances deemed by the inpatient hospitalist to be at high risk for readmission without the use of any specific morbidity rating scale. A TMC appointment included medication reconciliation, review of hospital records and outpatient records when available, and history and physical examination. We ordered labs and radiologic studies when indicated. We ensured every patient had a follow-up appointment with a primary care or specialist physician. We referred patients for home health services as needed. We compared the readmission rate of patients seen at TMC to readmission rates at Mission Hospital for the first six months of 2016.
Results: Of 181 patients seen at TMC from January-June 2016, 155 patients had Medicare insurance with 6 patients (4%) being readmitted to the hospital; 26 patients had HMO or PPO insurance with 1 patient being readmitted. Statistical analysis was done only for patients with Medicare insurance since sample size for patients with HMO or PPO insurance was small. The readmission rate of Medicare patients followed at TMC (4%) was significantly lower than Mission Hospital reported readmission rate for Medicare insurance in 2016 (16%), p <0.01. Statistical calculations were performed using chi-squared analysis.
Conclusions: Our data suggests post-hospital follow-up at TMC for high risk patients within 1 week of discharge may reduce readmissions. This improved outcome is likely related to early reevaluation, providing necessary services and connecting patients with primary care physicians or subspecialist physicians.