An Interprofessional Primary Care Based Transition of Care Clinic to Reduce Hospital Readmission

Hospital readmission is a major burden for patients, caregivers, and health systems. One study of Medicare fee-for-service patients found that 1 in 5 are rehospitalized within 30 days of discharge. In 2011, there were 3.3 million readmissions in the United States across all payers contributing to 41.3 billion in total hospital costs. The Affordable Care Act authorized the Centers for Medicare and Medicaid Services to reduce payment to hospitals with excessive rates of rehospitalization, creating substantial financial incentive for health systems to reduce readmissions. While the impact of hospital readmission on health systems is important, readmission also generates a significant financial and psychological burden for families and caregivers. Therefore, as we seek to provide high quality, patient centered care, one area of focus must be in reductions in hospital readmission.

Nall, R. W.,  Herndon, B., Mramba, L. K., Vogel-Anderson, K., Hagen, M. G., (2020). An Interprofessional Primary Care Based Transition of Care Clinic to Reduce Hospital Readmission. The American Journal of Medicine doi: 10.1016/j.amjmed.2019.10.040