Evaluating a Mobile Integrated Health Transitional Care Program to Reduce Readmissions: Findings From a...

The period following hospital discharge marks a precarious transition for older adults across medical, functional, and social domains. Paramedic-led mobile integrated health (MIH) programs offer a promising approach to bridging gaps in care, though their effectiveness in transitional care remains poorly characterized. The objective of this study was to evaluate the association of the Paramedic Assisted Community Evaluation (after) Discharge (PACED) intervention with 30-day rehospitalization rates among frail older adults.

In this prospective observational study, the clinical team offered older adults discharged from an urban academic medical center a paramedic-delivered home visit within 72 h. Patients who lived outside the program's geographical catchment area, did not have a system-affiliated primary care doctor, or who declined visits served as a comparator group to create a natural experiment. The primary outcome was 30-day rehospitalization. Secondary outcomes included 30-day emergency department (ED) utilization without admission. The characteristics of the sample and the content of the PACED visits for enrolled patients were presented descriptively. Modified Poisson regressions were used to estimate relative risks (RR) for 30-day rehospitalization and ED utilization, adjusting for demographics, comorbidities, frailty, and prior healthcare use with 95% confidence intervals (CIs).

Of 297 subjects, 190 received the PACED intervention (median age 82.7, 66.8% female) and 107 served as comparators (median age 81.3, 58.0% female). Thirty-day rehospitalization was lower among PACED participants (12.6% vs. 21.5%, adjusted RR 0.45, 95% CI: 0.26-0.77, p = 0.003), and they experienced fewer 30-day ED visits (11.5% vs. 18.7%, adjusted RR 0.58, 95% CI: 0.33-0.98, p = 0.05).

An in-home mobile integrated health (MIH) transitional care program for frail older adults after hospital discharge was associated with lower 30-day readmission rates. These findings highlight MIH as a promising model to support aging in place and suggest its potential value for adoption within age-friendly health systems.