title: Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population.
abstract: BACKGROUND
  Care transition programs can potentially reduce 30 day readmission; however, the effect on long-term hospital readmissions is still unclear.
  
  
  OBJECTIVE
  We compared short-term (30 day) and long-term (180 day) utilization of participants enrolled in care transitions versus those matched referents eligible but not enrolled.
  
  
  METHODS
  This cohort study was conducted from January 1, 2011 until June 30, 2013 within a primary care academic practice.
  
  
  METHODS
  Patients at high risk for hospital readmission based on age and comorbid health conditions had participated in care transitions group (cases) or usual care (referent).
  
  
  METHODS
  The primary outcomes were 30, 90, and 180 day hospital readmissions.. Secondary outcomes included: mortality; emergency room visits and days; combined rehospitalizations and emergency room visits; and total intensive care unit days. Cox proportional hazard models using propensity score matching were used to assess rehospitalization, emergency room visits and mortality. Poisson regression models were used to compare the numbers of hospital days.
  
  
  RESULTS
  Compared to referent (n=365), Mayo Clinic Care Transitions patients exhibited a lower 30 day rehospitalization rate compared to referent; 12.4% (95% CI 8.9-15.7) versus 20.1% (95% CI 15.8-24.1%), respectively (P=0.002). At 180-days, there was no difference in rehospitalization between transitions and referent; 39.9% (95% CI 34.6-44.9%) versus 44.8% (95% CI 39.4-49.8%), (P=0.07).
  
  
  CONCLUSIONS
  We observed a reduction in 30 day rehospitalization rates among those enrolled in care transitions compared to referent. However, this effect was not sustained at 180 days. More work is needed to identify how the intervention can be sustained beyond 30 days.
authors.affiliation: Division of Primary Care Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Kogod Center of Aging, Mayo Clinic, Rochester, MN, USA. Electronic address: takahashi.paul@mayo.edu.
authors.forename: Paul Y
authors.initials: PY
authors.lastname: Takahashi
authors.affiliation: Division of Health Care Policy & Research, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Naessens
authors.affiliation: Division of Health Care Policy & Research, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Peterson
authors.affiliation: Division of Health Care Policy & Research, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Parvez A
authors.initials: PA
authors.lastname: Rahman
authors.affiliation: Division of Health Care Policy & Research, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
authors.affiliation: Division of Health Care Policy & Research, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Finnie
authors.affiliation: University of Arkansas, Little Rock, AR, USA.
authors.forename: Audrey J
authors.initials: AJ
authors.lastname: Weymiller
authors.affiliation: Division of Primary Care Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Bjorg
authors.initials: B
authors.lastname: Thorsteinsdottir
authors.affiliation: Division of Primary Care Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Kogod Center of Aging, Mayo Clinic, Rochester, MN, USA.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Hanson
mesh_terms: D015331:Cohort Studies; D003631:Day Care, Medical; D004636:Emergency Service, Hospital; D006761:Hospitals; D006801:Humans; D008134:Long-Term Care; D010351:Patient Discharge; D010359:Patient Readmission; D010360:Patient Transfer; D011320:Primary Health Care; D012189:Retrospective Studies
keywords: Care transitions; Geriatric; Hospitalization