Background: Transitional care programs are being established to improve medical care for at-risk adults. Evidence exists that Care Transition Program(s) (CTP) reduce hospital readmissions. We conducted a retrospective cohort study to identify which process measures in our CTP were likely to contribute to a reduction in the 30-day readmission rates.
Methods: At-risk patients were identified and seen soon after the index hospital discharge. Areas of emphasis during these visits included hospital follow-up care, medication reconciliation, and psychosocial aspects of care, among others.
Results: Medication reconciliation was performed in 87%, and an assessment of the psychosocial aspects of care was assessed in 71.7% of the patients.
Discussion: This pilot study of CTP showed promising results of an 11% 30-day readmission rate, compared to a national rate of 19.6%. Further studies that integrate standardized documentation during CTP visits will be important to determine important factors involved in providing better quality of care.