Background: Hospital readmissions within 30 days are a major indicator of healthcare quality and required reporting by hospitals secondary to the Hospital Readmissions Reduction Program. Transitional Care Management (TCM) visits are a structured approach aimed to prevent avoidable readmissions via provision of support and resources through timely hospital follow-ups and care coordination. This study aimed to measure the association of TCM utilization and 30 day rehospitalizations when accounting for length of stay of the index hospitalization, rural-urban locality, and primary care access.
Methods: A retrospective review was conducted using secondary electronic health records of patients discharged between June 2023 and June 2024 from a large academic health system. Eligible encounters included patients with a chronic condition primary diagnosis, age of 18 years or older, and discharge to home. Variables of interest included 30-day rehospitalization , Rural-Urban Commuting Area categorizing A score (RUCA), primary care provider (PCP) access, TCM utilization, and length of stay (LOS) and were collected from chart review and categorized. Multivariate regression analyses were conducted using R with results summarized using odds ratios, 95% confidence intervals, and p-values. This study was approved by the appropriate institutional review board.
Results: Of these 27,106 patients, 2,865 (10.6%) were readmitted within 30 days and 3,938 (14.5%) utilized TCM services (Table 1). After adjustment, TCM utilization was significantly associated with lower odds of readmission (0.79, (0.70-0.89), p< 0.0001). PCP access was also independently protective (0.82, (0.76-0.89), p< 0.0001). Conversely, longer LOS demonstrated a strong association of 30-day readmissions (LOS ≥ 5 days vs. 1-2 days (2.26, [2.06-2.47]), p< 0.001). Rural-urban locality was not significantly associated with readmission (Table 2).
Conclusions: From this study, TCM utilization was found to be associated with a reduction in 30-day readmissions within patients with chronic conditions. These findings emphasize the importance of transitional care interventions and support expansion of TCM engagement for patients with long hospital stays or limited primary care access. Strengthening post-discharge coordination may help mitigate preventable readmissions in rural communities.
