Factors Affecting 30-day Readmission Rates: A Longitudinal Study Following An Outpatient Clinic

Intro: Hospital readmission rates are indicators for assessing quality of care in post-acute settings. Preventable readmissions are a particular source of financial burden for hospitals.

Objective: Peconic Bay Medical Center (PBMC) tracks 30 -day readmissions as part of hospital quality measures. This study expanded on our previous study from 2020, “Improving Transition of Care: The Effect of Telephone Communication on Post-Hospitalization Primary Care Follow-up,” which demonstrated that post-hospitalization PCP follow-up improved with the use of telephone calls to facilitate scheduling appointments

We further examined hospital discharges from Aug 2021- Jan 2022 who were established patients of our Family Medicine (FM) Residency clinic, added further steps to have the hospitalist facilitate appointments to outpatient, and have a completed discharge summary available.

Methods/Discussion: The Quality team at PBMC tracked patients with 30-day readmissions and the diagnoses associated with those readmissions. N=225. We showed there was a significant decrease in readmissions from August to January. We were able to discern some factors associated but not all. This study showed there was no significant difference in readmission rates whether an appt was made or not after discharge. Overall readmission rates Aug 2021-Jan 2022: 36 patients, 16% 17 patients, 8%-No appointment 19 patients, 8%-Had appointment.

36% of cases readmitted were similar diagnoses to their initial visit diagnosis. These patients may not be preventable readmissions, but should be prioritized for post hospital follow up appointments.

Conclusions: Appointments made at the time of discharge can increase patient compliance. Further steps that could help decrease readmission rates in frequent readmission patients would be capturing those who no show in the outpatient setting to discern factors-insurance, transportation?

Further interventions are needed on decreasing admissions for the frequent readmission patients however data shows this may be difficult, instead we propose we also focus on those with a moderate lace score, who are less sick and may be more able to be followed outpatient to reduce readmission