Post-Acute Care: Advancing Population Health Interventions, Risk Assessment, and Implications for Readmissions and Cost-Effectiveness through Telehealth

Introduction: It is essential to provide transitional care to high-risk populations in their most vulnerable states through effective post-hospitalization follow-up. However, the effectiveness of virtual interventions could be established through the examination of adverse events, medical compliance, decreased hospital readmission rates, and cost-effectiveness. Methods: A new virtual post-discharge clinic was established to provide innovative multimodal interventions including education, identification of adverse events, medical adherence, social support, and coordination with primary care providers. We established innovated processes for referrals, scheduling, and communication for patients and stakeholders. Leadership was critical to sustaining transitional patient care for the organization while working with limited budgets. Results: Post-discharge visits were stratified based on the risk of readmission, and over 90% of patients received virtual appointments. Our interventions reduced the incidence of readmission by 33% among patients with a high risk of readmission; no differences were observed in patients with a low to medium risk of readmission. Conclusion: The effectiveness of telehealth transitional care interventions has a significant impact on reducing readmissions in high-risk populations. Our interventions provided comprehensive patient-centered care in the post-discharge setting.