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

BACKGROUND: Hospital readmission is a major burden for patients, caregivers, and health systems. Some readmissions may be avoided through timely follow-up in a transition clinic with an interprofessional approach to care. METHODS: We prospectively evaluated a cohort of adults 18 years, n = 203, who are patients of an affili-ated academic internal medicine clinic with University of Florida Health and discharged from the hospital between November 1, 2016, and May 1, 2017. We sought to determine if follow-up in an interprofessional transition-of-care (TCM) clinic after discharge was associated with a reduction in hospital readmission when compared to standard follow-up at 30, 60, and 90 days. RESULTS: Follow-up in the TCM clinic was associated with reduced odds of hospital readmission at 90 days by 60%, (odds ratio [OR]: 0.40, P = 0.044, 95% confidence interval [CI] 0.16-0.97). Although the clinic failed to demonstrate a statistically significant association between clinic follow-up and in readmis-sion at 30 (OR: 0.66, P = 0.36, 95% CI 0.27-1.59) and 60 days (OR: 0.67, P = 0.31, 95% CI 0.31-1.47), fewer readmissions were seen in patients seen by the TCM clinic. CONCLUSIONS: A primary care nested interprofessional transition-of-care clinic was associated with a reduction in hospital readmission. (C) 2019 Elsevier Inc. All rights reserved.