Key result
A multidisciplinary transitions-of-care clinic reduced 30-day readmission rates among high-risk veterans compared to the preimplementation period (9.2% vs 11.4%, P=0.04).
Why the study?
Data are limited regarding the efficacy of care transitions initiatives in reducing hospital readmissions, especially among rural patients.
Does a multidisciplinary transitions-of-care clinic reduce 30-day readmission rates in high-risk veterans?
Observational
No
Does a multidisciplinary transitions-of-care clinic reduce 30-day readmission rates in high-risk veterans?
A multidisciplinary transitions-of-care clinic offering virtual and in-person visits significantly reduced 30-day hospital readmissions among high-risk veterans, particularly those with congestive heart failure.
Answers are grounded in this paper and cite their sources.
May support TOCC use in high-risk veterans; extends care transitions data to rural VA settings but remains hypothesis-generating.
BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.
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Griffin et al. (2021) conducted an observational in High risk for 30-day hospital readmission. Multidisciplinary transitions-of-care clinic (TOCC) vs. Preimplementation period (non-TOCC follow-up) was evaluated on Monthly 30-day patient readmission rate (19.2% relative reduction, p=.04). A multidisciplinary transitions-of-care clinic reduced 30-day readmission rates among high-risk veterans compared to the preimplementation period (9.2% vs 11.4%, P=0.04).
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