title: A multidisciplinary intervention for reducing readmissions among older adults in a patient-centered medical home.
abstract: OBJECTIVE
  To evaluate the effectiveness of a multidisciplinary practice model consisting of medical providers, clinical pharmacists, and social workers on reducing 30-day all-cause readmissions.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  This study included adults 60 years or older discharged from a large academic medical center. Patients were grouped as either receiving the primary care-based transitional care program (intervention group) or usual care (control group) after an index hospitalization. Only 1 index hospitalization was included per patient. All-cause 30-day readmission rates between propensity score matched study groups were analyzed by intention-to-treat, per protocol, and as-treated methods. Secondary outcomes included time to readmission, subgroup analysis, process measures, and cost avoidance influence of covariates on chance of readmission measured by logistic regression.
  
  
  RESULTS
  Over 27 months, 19,169 unique patients had 18,668 index hospitalizations and 572 interventions scheduled after discharge. Among matched subjects, 30-day readmission rates were not significantly different between those scheduled for the intervention and those never scheduled (21% vs 17.3%, respectively; P = .133). However, when those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P < .001). Likewise, time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015) and potential cost avoidance was observed only when the intervention was completed.
  
  
  CONCLUSIONS
  A community-based multidisciplinary transitional care program may reduce hospital readmissions among older adults.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Stranges
authors.forename: Vincent D
authors.initials: VD
authors.lastname: Marshall
authors.forename: Paul C
authors.initials: PC
authors.lastname: Walker
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hall
authors.forename: Diane K
authors.initials: DK
authors.lastname: Griffith
authors.affiliation: University of Michigan College of Pharmacy and Health System, 4201 Plymouth Rd, SPC 5797, Ann Arbor, MI 48109. E-mail: remingtn@med.umich.edu.
authors.forename: Tami
authors.initials: T
authors.lastname: Remington
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000704:Analysis of Variance; D015331:Cohort Studies; D005260:Female; D015577:Geriatric Assessment; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D033183:Interdisciplinary Communication; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010348:Patient Care Team / Q000458:organization & administration*; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data*; D018802:Patient-Centered Care / Q000458:organization & administration*; D012189:Retrospective Studies; D000069341:Transitional Care / Q000458:organization & administration*