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January 10, 2026COVID0 citationsOpen Access

Hospital Readmission, Transitions of Care Bundle, and a Cohort of COVID-19 Patients—An Observational Study

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JBJenny Firth BernardJCJazmin CascanteTNThemba Nyirenda

Key Result

The Transitions Of Care Bundle (TOCB™) enabled all patients to be discharged home, compared to only 36% in the control group, suggesting a reduced risk of readmission.

Key Points

  • Evaluate how the Transitions Of Care Bundle affects outcomes like readmission and mortality in COVID-19 patients post-discharge.
  • Retrospective observational study
  • Analyzed electronic health record data for 243 COVID-19 patients
  • Compared outcomes of 65 TOCB™ patients to 178 controls
  • Evaluated demographics, comorbidities, readmissions, mortality, and payor status
  • TOCB™ cohort showed higher percentage of Hispanic patients (56.92% vs. 48.3%)
  • 100% of TOCB™ patients were discharged home without additional services compared to 36% of controls
  • TOCB™ implementation linked to shorter hospital stays, potential reduction in readmission rates, and fewer emergency department visits

Structured PICO

Does the Transitions Of Care Bundle (TOCB™) improve post-discharge outcomes in COVID-19 patients?

P
Population
243 COVID-19 patients (65 TOCB™, 178 control) during the initial pandemic months at a large academic facility in Northeast New Jersey (NJ).
I
Intervention
Transitions Of Care Bundle (TOCB™) post-discharge
C
Comparator
Control cohort
O
Outcome
Patient outcomes post-discharge including readmissions, mortality, length of hospital stay, and emergency department visits

Implementation of a Transitions of Care Bundle for COVID-19 patients is associated with improved discharge dispositions, shorter hospital stays, and fewer subsequent healthcare encounters.

Abstract

Vulnerable populations experience higher mortality and readmission after hospital discharge. We sought to evaluate the impact of the Transitions Of Care Bundle (TOCB™) on COVID-19 patient outcomes post-discharge compared to a control cohort. This retrospective study used electronic health record data collected for 243 COVID-19 patients (65 TOCB™, 178 control) during the initial pandemic months at a large academic facility in Northeast New Jersey (NJ). Data included demographics, comorbidities, readmissions, mortality, and payor. The TOCB™ cohort had proportionally more Hispanic patients (56.92% vs. 48.3%, p = 0.0885). All TOCB™ patients were discharged home without needing additional services, compared to only 36% of the control group. The implementation of TOCB™ was associated with shorter hospital stays, a potential decrease in readmission rates, and fewer emergency department visits. These results imply that well-coordinated post-discharge services are linked to a diminished risk of mortality, possible hospital readmission, and other adverse health outcomes.

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Cite This Study

Bernard et al. (2026) studied this question. The Transitions Of Care Bundle (TOCB™) enabled all patients to be discharged home, compared to only 36% in the control group, suggesting a reduced risk of readmission.

synapsesocial.com/papers/696321d091e05aa366cb8119https://doi.org/10.3390/covid6010013
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