Virtual Transition of Care Clinics and Associated Readmission Rates: 3-Year Retrospective Cohort Study

Area of Science:

• Health Services Research
• Digital Health Interventions
• Patient Care Coordination

Background:

• Hospital readmissions represent a significant financial burden, costing an estimated $17 billion annually.
• While timely follow-up reduces readmissions, access limitations hinder its effectiveness.
• Traditional transitions of care clinics face logistical and financial challenges due to physical space requirements.

Purpose of the Study:

• To evaluate the effectiveness of a virtual transitions of care (VToC) clinic.
• To assess the VToC clinic's impact on reducing 30-day hospital readmissions.
• To determine the VToC clinic's role in improving postdischarge care coordination.

Main Methods:

• A hospitalist-led VToC clinic was implemented at UC San Diego Health.
• The study included 2314 patients from September 2021 to September 2024.
• Regression analysis compared VToC patients to a benchmark group to assess readmission rates.

Main Results:

• The VToC clinic achieved a 14.9% 30-day readmission rate, significantly lower than the benchmark's 20.1% (P<.001).
• Non-participation in the VToC clinic was associated with a higher likelihood of readmission (OR=1.37; P<.001).
• The greatest reduction in readmissions was seen in patients with moderate readmission risk (LACE+ score 50-75).

Conclusions:

• Virtual transitions of care clinics are a feasible and effective strategy for postdischarge care.
• VToC clinics significantly reduce hospital readmissions and enhance care coordination.
• This model supports the quadruple aim: better outcomes, patient experience, cost-efficiency, and equity.