Efficacy of a Transition Clinic on Hospital Readmissions

Chakravarthy, Vidya; Ryan, Maureen C.; Jaffer, Amir K.; Golden, Robyn; McClenton, Regina; Kim, Jisu; Press, Irwin; Johnson, Tricia J.

doi:10.1016/j.amjmed.2017.08.037

Cited by 18 publications

(25 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Transitional care clinics (n = 7) Transitional care clinics were assessed in seven studies and were often combined with telephone and/or nurse follow up. A retrospective study [35] reported reduced rehospitalisation for patients who completed a scheduled transition clinic appointment compared with those who neither attended the transition clinic nor their primary care physician. Similarly, a reduction in rehospitalisation, as well as potential Medicare savings were observed by Baldwin et al [36] for patients attending a multidisciplinary discharge clinic in the USA.…”

Section: Service Provider and Approachmentioning

confidence: 99%

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

et al. 2020

View full text Add to dashboard Cite

Key summary points Aim This scoping review examined the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs. Findings While some studies report positive outcomes on hospital utilisation, the evidence is limited for their effectiveness on emergency department attendances, institutionalisation, function, and cost-effectiveness. Message Intermediate care including transitional care interventions were associated with reduced hospital stay but this finding was not universal. Electronic supplementary material The online version of this article (10.1007/s41999-020-00365-4) contains supplementary material, which is available to authorized users.

show abstract

Section: Service Provider and Approachmentioning

confidence: 99%

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

et al. 2020

View full text Add to dashboard Cite

show abstract

“…One promising intervention to improve care transitions for medically complex and socially vulnerable patients is interdisciplinary primary care-led transition clinics. 8 , 10 , 11 The transition clinic (TC) team’s composition can take many forms depending on the context but often includes a primary care physician and/or advanced practice nurse, social worker or community health worker, and psychologist. 10 , 12 , 13 Together they form an interdiscipinary team that provides time-limited, patient-centered support to individuals of a target population during a specified care transition.…”

Section: Transition Clinics As a Step Toward Equitable Care Transitiomentioning

confidence: 99%

“…One promising intervention to improve care transitions for medically complex and socially vulnerable patients is interdisciplinary primary care-led transition clinics. 8,10,11…”

Section: Transition Clinics As a Step Toward Equitable Care Transitionsmentioning

confidence: 99%

Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary

Malebranche

Sarivalasis²,

Peters³

et al. 2020

J Prim Care Community Health

View full text Add to dashboard Cite

Transitions in care are key junctions during which care coordination, communication, and individualized support are required to ensure optimal health outcomes for patients. This is particularly true for patients who face social disparities, such as poverty, limited health literacy, or belonging to a racial or ethnic minority, who are particularly at risk for experiencing poor care transitions. Interdisciplinary primary care-led transition clinics are an intervention that have shown promise in improving care transitions for diverse patient populations, including those that face social disparities, but their role in improving transitions in cancer care remains largely untapped. In this commentary we highlight why the time-limited support of an interdisciplinary primary care-led transition clinic that targets socially vulnerable cancer patients holds the promise of achieving more equitable healthcare access, healthcare quality, and ultimately more equitable health outcomes for cancer patients.

show abstract

“…While earlier work has primarily focused on readmission predictive methods , there has only been limited attention given to specific interventions with the potential to reduce readmissions; and that has focused mostly on post-discharge care [ 9 – 11 ]. Earlier work on predictive methods for hospitalizations have been successful but focused on specific diseases [ 12 – 14 ].…”

Section: Introductionmentioning

confidence: 99%

Prescriptive analytics for reducing 30-day hospital readmissions after general surgery

Bertsimas

Paschalidis

et al. 2020

PLoS ONE

View full text Add to dashboard Cite

Introduction New financial incentives, such as reduced Medicare reimbursements, have led hospitals to closely monitor their readmission rates and initiate efforts aimed at reducing them. In this context, many surgical departments participate in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which collects detailed demographic, laboratory, clinical, procedure and perioperative occurrence data. The availability of such data enables the development of data science methods which predict readmissions and, as done in this paper, offer specific recommendations aimed at preventing readmissions. Materials and methods This study leverages NSQIP data for 722,101 surgeries to develop predictive and prescriptive models, predicting readmissions and offering real-time, personalized treatment recommendations for surgical patients during their hospital stay, aimed at reducing the risk of a 30-day readmission. We applied a variety of classification methods to predict 30-day readmissions and developed two prescriptive methods to recommend pre-operative blood transfusions to increase the patient's hematocrit with the objective of preventing readmissions. The effect of these interventions was evaluated using several predictive models. Results Predictions of 30-day readmissions based on the entire collection of NSQIP variables achieve an out-of-sample accuracy of 87% (Area Under the Curve-AUC). Predictions based only on pre-operative variables have an accuracy of 74% AUC, out-of-sample. Personalized interventions, in the form of pre-operative blood transfusions identified by the prescriptive methods, reduce readmissions by 12%, on average, for patients considered as candidates for pre-operative transfusion (pre-operative hematoctic <30). The prediction accuracy of the proposed models exceeds results in the literature.

show abstract

Efficacy of a Transition Clinic on Hospital Readmissions

Cited by 18 publications

References 13 publications

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary

Prescriptive analytics for reducing 30-day hospital readmissions after general surgery

Contact Info

Product

Resources

About