Background: Studies have shown about 2 million patients are readmitted to hospitals nationwide yearly. Data from the Center for Health Information and Analysis (CHIA) estimate the annual cost of readmissions of Medicare patients amounts to billions of dollars annually; about half this cost may be preventable. Hospitals are working to create programs to decrease readmission rates.

Methods: Using a prospective single-site cohort design, we developed a Transitional Medical Clinic (TMC) at Mission Hospital (a community hospital in Mission Viejo, CA) to follow up hospital patients within 1 week of discharge. We then collected data to determine if the clinic would decrease 30 day readmissions. We followed 1527 patients from January 2017 to September 2018 . We divided these patients into two groups. The TMC group (n=1083 patients) included patients scheduled and seen by the TMC within one week post hospital discharge. The non-TMC group (n=444) included patients that were scheduled for TMC but either did not show up or canceled their appointment. Criteria for TMC referral included patients with PPO, HMO, or Medicare insurance deemed by the hospitalist to be at high risk for readmission. The TMC appointment included review of hospital records and outpatient records, medication reconciliation, history and physical examination, and patient education. We ordered labs and radiologic studies when indicated. We ensured every patient had a follow up appointment with a primary care doctor and a specialist when appropriate. We referred patients for home health services as needed.

Results: For the TMC group, 96 patients out of 1083 were readmitted to the hospital with readmission rate of 9%. For the non-TMC group, 83 out of 444 patients were readmitted to the hospital with readmission rate of 18.5%. The reduced readmission rate of the TMC group compared to the non-TMC group was statistically significant (p <0.01).

Conclusions: Our data suggests post-hospital follow-up at TMC for high risk patients within 1 week of discharge may reduce readmissions. This improved outcome is likely related to early reevaluation, providing necessary education and services, and connecting patients with primary care physicians or sub specialists.