• Rozalina G McCoy, Stephanie M Peterson, Lynn S Borkenhagen, Paul Y Takahashi, Bjorg Thorsteinsdottir, Anupam Chandra, and James M Naessens.
• Departments of Medicine, Division of Community Internal Medicine.
• Med Care. 2018 Aug 1; 56 (8): 693-700.

BackgroundCare transitions programs have been shown to reduce hospital readmissions.ObjectivesThe main objective of this study was to evaluate effects of the Mayo Clinic Care Transitions (MCCTs) Program on potentially preventable and nonpreventable 30-day unplanned readmissions among high-risk elders.Research DesignThis was a retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care.SubjectsThe subjects were primary care patients, who were 60 years or older, at high-risk for readmission, and hospitalized for any cause between January 1, 2011 and June 30, 2013.MeasuresHospital readmission within 30 days. The 3M algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions, a subset of preventable readmissions identified by the 3M algorithm, were also assessed.ResultsThe study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83 y) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate [12.4% (95% confidence interval: CI, 8.9-15.7) vs. 20.1% (15.8-24.1); P=0.004] resulting from a decrease in potentially preventable readmissions [8.4% (95% CI, 5.5-11.3) vs. 14.3% (95% CI, 10.5-17.9); P=0.01]. Few potentially preventable readmissions were for ambulatory care sensitive conditions (6.7% vs. 12.0%). The rates of nonpotentially preventable readmissions were similar [4.3% (95% CI, 2.2-6.5) vs. 6.7% (95% CI, 4.0-9.4); P=0.16]. Potentially preventable readmissions were reduced by 44% (hazard ratio, 0.56; 95% CI, 0.36-0.88; P=0.01) with no change in other readmissions.ConclusionsThe MCCT significantly reduces preventable readmissions, suggesting that access to multidisciplinary care can reduce readmissions and improve outcomes for high-risk elders.

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