An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission

Hospital readmission is a major burden for patients, caregivers, and health systems. Some readmissions may be avoided through timely follow-up in a transition clinic with an interprofessional approach to care.

We prospectively evaluated a cohort of adults >18 years, n = 203, who are patients of an affiliated academic internal medicine clinic with University of Florida Health and discharged from the hospital between November 1, 2016, and May 1, 2017. We sought to determine if follow-up in an interprofessional transition-of-care (TCM) clinic after discharge was associated with a reduction in hospital readmission when compared to standard follow-up at 30, 60, and 90 days.

Follow-up in the TCM clinic was associated with reduced odds of hospital readmission at 90 days by 60%, (odds ratio [OR]: 0.40, P = 0.044, 95% confidence interval [CI] 0.16-0.97). Although the clinic failed to demonstrate a statistically significant association between clinic follow-up and in readmission at 30 (OR: 0.66, P = 0.36, 95% CI 0.27-1.59) and 60 days (OR: 0.67, P = 0.31, 95% CI 0.31-1.47), fewer readmissions were seen in patients seen by the TCM clinic.

A primary care nested interprofessional transition-of-care clinic was associated with a reduction in hospital readmission.