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. 2021 Oct;16(10):583-588.
doi: 10.12788/jhm.3659.

An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population

Benjamin R Griffin  1   2 , Neeru Agarwal  1   2 , Rachana Amberker  1   2 , Jeydith A Gutierrez Perez  1   2 , Kelsi Eichorst  1 , Jennifer Chapin  1 , Amy C Schweitzer  1 , Mariko Hagiwara  1   2 , Chaorong Wu  3 , Patrick Ten Eyck  3 , Heather Schacht Reisinger  1   2 , Mary Vaughan-Sarrazin  1   2 , Ethan F Kuperman  2 , Kevin Glenn  1   2 , Diana I Jalal  1   2
Affiliations

An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population

Benjamin R Griffin et al. J Hosp Med. 2021 Oct.

Abstract

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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Figures

FIG
FIG
Run Chart Showing 30-Day Readmission Rates by Month Over Time in the Total Hospital Population. The gray bars represent the quarterly 30-day readmission rate. The dashed line is the median 30-day readmission rate for the 12-month intervention period.
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