• Bjorg Thorsteinsdottir, Stephanie M Peterson, James M Naessens, Rozalina G Mccoy, Gregory J Hanson, Latonya J Hickson, Christina Yy Chen, Parvez A Rahman, Nilay D Shah, Lynn Borkenhagen, Anupam Chandra, Rachel Havyer, Aaron Leppin, and Paul Y Takahashi.
• Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota.
• J Hosp Med. 2019 Jun 1; 14 (6): 329-335.

BackgroundAlthough posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.ObjectiveTo identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions.DesignRetrospective cohort.PatientsA total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013.SettingMidwest primary care practice in an integrated health system.InterventionEnrollment in a CTP during acute hospitalization.MeasurementsThe primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare.ResultsThe overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission.ConclusionsNo single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

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