Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex...

Care transition programs can potentially reduce 30 day readmission; however, the effect on long-term hospital readmissions is still unclear.

We compared short-term (30 day) and long-term (180 day) utilization of participants enrolled in care transitions versus those matched referents eligible but not enrolled.

This cohort study was conducted from January 1, 2011 until June 30, 2013 within a primary care academic practice.

Patients at high risk for hospital readmission based on age and comorbid health conditions had participated in care transitions group (cases) or usual care (referent).

The primary outcomes were 30, 90, and 180 day hospital readmissions.. Secondary outcomes included: mortality; emergency room visits and days; combined rehospitalizations and emergency room visits; and total intensive care unit days. Cox proportional hazard models using propensity score matching were used to assess rehospitalization, emergency room visits and mortality. Poisson regression models were used to compare the numbers of hospital days.

Compared to referent (n=365), Mayo Clinic Care Transitions patients exhibited a lower 30 day rehospitalization rate compared to referent; 12.4% (95% CI 8.9-15.7) versus 20.1% (95% CI 15.8-24.1%), respectively (P=0.002). At 180-days, there was no difference in rehospitalization between transitions and referent; 39.9% (95% CI 34.6-44.9%) versus 44.8% (95% CI 39.4-49.8%), (P=0.07).

We observed a reduction in 30 day rehospitalization rates among those enrolled in care transitions compared to referent. However, this effect was not sustained at 180 days. More work is needed to identify how the intervention can be sustained beyond 30 days.