Improving Telehealth Transition of Care Programs Focused on Readmission Reduction

Suboptimal transitional care from the hospital to home can result in poor health outcomes, increased costs, and readmissions. Telehealth-based transitional care programs have shown some improvements in readmission rates; however, it is unclear why some patients benefit while others do not. This study evaluated a connected transitional care (CTC) program that provided high-risk patients with timely post-discharge telehealth appointments conducted by a nurse practitioner. Our focus was on understanding why some patients participating in the program benefit and are not readmitted while others are readmitted.

We analyzed readmission rates for patients referred to the program and compared those who engaged, by completing a telehealth visit, to those who did not. For those patients who did engage, we conducted chart reviews of a subset of patients who were not readmitted compared with those who were readmitted to extract themes and understand differences that could serve to improve the CTC program.

Of 1374 patients referred to the CTC program, 443 (32.2%) engaged by completing a telehealth visit. Those who engaged in the program had a readmission rate of 18.7% compared with 21.3% for those who did not, resulting in a relative risk reduction of 12%. Chart reviews comparing patients who engaged and were not readmitted (32 charts reviewed) with those who were readmitted (18 charts reviewed) revealed several differences. Patients who were not readmitted were seen sooner after discharge, had greater family/caregiver involvement, had social needs addressed, required less language interpretation, and had fewer instances of altered mental status.

This study suggests that a telehealth transition program may reduce readmissions, although a more rigorous statistical analysis is needed. Importantly, the qualitative chart review suggests several areas for improvement, including engaging family/caregivers, providing better social need support, and developing ways to support behavioral health.