Implementing Postdischarge Transition Care in a Hospitalist System

1National Taiwan University Hospital, Taipei, Taiwan

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 207


Postdischarge care is a challenge, and the readmission rate remains high especially in elderly patients. Because discontinuity is a concern after discharge, post‐discharge transition care (PDTC) needs to be incorporated into hospitalist‐care systems.


To evaluate the usefulness of PDTC in hospitalist‐care systems.


We conducted this prospective study from December 2009 to May 2010 in a hospitalist ward of a referral center in Taiwan. Patients were enrolled in the first 2 months as an observation group, whereas those were enrolled in the latter 4 months as an intervention group. Within 30 days after discharge, the intervention was performed with PDTC using regular telephone service for contact and for call‐in counseling. In addition, a hospitalist‐run clinic was implemented for patients requiring follow‐up. In our preliminary result during the study period, we enrolled 94 and 219 patients in the observation and intervention groups, respectively. They had similar baseline characteristics at initial admission and at discharge. In the postdischarge course, worsening indicators in telephone contact and self‐reporting new/worsening symptoms in counseling were both high risks for unplanned read‐mission. Undergoing implementing PDTC, hospitalist‐run clinic visits decreased significantly. In addition, those who received PDTC had a lower probability of unplanned readmission and death than those who did not receive it (Fig. 1). In multivariate analysis, not receiving PDTC, not visiting the hospitalist‐run clinic, and having an underlying malignancy were independent associated factors for 30‐day post‐discharge readmission and death.


PDTC using telephone calls and a hospitalistrun clinic demonstrated good performance in reducing postdischarge readmissions and deaths. For inpatients with general medical illnesses, we believe the PDTC strategy is promising for improving the quality of care after discharge.

FIGURE 1. Probability of nonreadmission within 30 days after discharge was plotted by the Kaplan–Meier method and compared using the log‐rank test (PDTC, postdischarge transition care).


C. C. Shu ‐ none; N. C. Hsu ‐ none; Y. F. Lin ‐ none; W. J. Ko ‐ none

To cite this abstract:

Shu C, Ko W. Implementing Postdischarge Transition Care in a Hospitalist System. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 207. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed May 24, 2019.

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