Background: Hospital readmissions within 30 days are a major quality and cost concern in healthcare. The 30-day all-cause readmission rate in the U.S. is approximately 14%, accounting for billions of dollars in health care expenditure (1,2). Evidence suggests a substantial portion of these readmissions are preventable (3). In response, hospitals are developing multifaceted interventions to improve transition of care and reduce readmission rates.
Purpose: We established a Transitional Medical Clinic (TMC) at Mission Hospital in Mission Viejo, California, to provide follow-up care for patients within one week of hospital discharge. TMC aimed to bridge the gap between inpatient and outpatient care by addressing post discharge needs and ensuring continuity of care. This study evaluated whether participation in the TMC was associated with a reduction in 30-day hospital readmissions.
Description: We conducted a prospective, single-site cohort study of patients discharged between January 2017 and August 2025. Participants were divided into two groups. The TMC group (n = 6,672) included patients who were scheduled for and attended a TMC visit within one week of hospital discharge. The non-TMC group (n = 1,812) included patients who were scheduled for a TMC visit but either did not attend or canceled their appointments.Eligibility for TMC referral included patients with PPO, HMO, or Medicare insurance identified by hospitalists as high risk for readmission. The standardized TMC visit included a comprehensive review of inpatient and outpatient medical records, medication reconciliation, a detailed history and physical examination, and patient education. Laboratory and radiologic studies were obtained as clinically indicated.The TMC was equipped to provide on-site treatments such as intramuscular (IM) furosemide, subcutaneous furosemide pump therapy, IV fluids, antibiotics, corticosteroids, antihypertensive agents, and nebulizer therapy. Each patient was also scheduled for follow-up with their primary care physician and appropriate specialists. Referrals for home health services and home Oxygen were arranged as appropriate.Among TMC participants, 628 of 6,672 patients (9%) were readmitted within 30 days, compared with 328 of 1,812 patients (18%) in the non-TMC group. The reduction in hospital readmission rate among the TMC group was statistically significant (p < 0.01).
Conclusions: Our findings indicate that post-hospital follow-up through a structured TMC within one week of discharge was associated with a significant reduction in 30-day readmissions among high-risk patients. Early outpatient reassessment facilitates timely management of unresolved medical issues, reinforces discharge instructions and medication adherence. In addition, it promotes continuity of care through connection to primary and specialty services. These results highlight the importance of timely, structured follow-up in improving outcomes and reducing hospital utilization among high-risk populations.