• Michael Baldino, Anne Marie Bonaguro, Sean Burgwardt, Andrea Lombardi, Cagney Cristancho, Chitsimran Mann, David Wright, Christopher Jackson, and Ankur Seth.
• Nassau University Medical Center; New York Institute of Technology College of Osteopathic Medicine at Arkansas State University. Electronic address: mbaldino@numc.edu.
• J Natl Med Assoc. 2021 Apr 1; 113 (2): 133-141.

BackgroundThe Center for Medicare and Medicaid Services (CMS) has targeted hospital readmissions, which cost $17 billion per year, as one potential solution to reduce rising health care costs. Studies have documented the ability of Transitions of care (TOC) services to reduce readmissions in high risk patients. However, the vast majority of studies have not explored TOC services for all-cause admissions nor TOC clinics led by hospitalists. The goal of this study is to provide preliminary data regarding the potential effectiveness of a hospitalist-led TOC clinic servicing all patients on hospital readmission rates.MethodsThis cross-sectional feasibility study analyzed patients on a tertiary hospital teaching service. All discharged patients from January 2016 to September 2018 were given an appointment at the TOC clinic within 14 days of discharge. The control group consisted of patients assigned to the teaching service from January 2018 to November 2018 that were not offered a TOC appointment.ResultsOverall, 1373 patients (n = 1373) were included in this study between January 2016 and September 2018. The control group consisted of 1000 patients who were not offered follow up in the TOC clinic while the TOC group consisted of 373 patients who did attend a follow up appointment in the TOC clinic. The study participants (n = 1373) included patients admitted to the hospital for any diagnosis and were analyzed for all cause readmission rates. The TOC group consisted of 52% African Americans, 52% Medicare patients and 8% Medicaid patients. Demographic information for the control group was not available. The TOC group had a statistically significant 42% decreased risk of being readmitted within 30 days of discharge (RR = 0.58, 95% CI: 0.40-0.83). These data showed a statistically significant difference between the TOC group and control group in relation to the incidence of 30-day readmissions (p-value = 0.002).ConclusionAmong Medicare and Medicaid beneficiaries and commercial health insurance patients, this hospitalist-led TOC intervention was associated with a statistically significant reduction in 30-day readmissions following discharge for all-cause hospital admissions.Copyright © 2020 National Medical Association. Published by Elsevier Inc. All rights reserved.

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