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Factors Associated With 30-Day Hospital Readmissions Among Participants in a Care Transition Quality Improvement Program

Discharge from hospital to home is a vulnerable period for older adults who have multiple care needs. The Safe Transitions for Elderly People (STEP) program is a care transition program for Medicare fee-for-service patients 75 years and older discharged to home from a community hospital. This quality improvement project (a) compares 30-day hospital readmission rates between 498 STEP participants and 722 patients eligible for STEP but not participating in the program, and (b) determines factors associated with readmissions during STEP. The STEP participants received intervention in 1 of 2 formats: 395 received a telephone-only intervention and 103 received a telephone plus home visit intervention. STEP participants had a lower 30-day hospital readmission rate than nonparticipants (i.e., those who could not be contacted for STEP participation; those who declined to participate). Results of binary logistic regressions showed 2 variables were significant predictors of readmissions: for the group of all STEP participants and the telephone-only intervention group, the (a) hospitalization within the previous year predicted readmission; for the telephone plus home visit group, the (b) degree of assistance needed with ambulation predicted readmission. Given the multifactor nature of readmissions, interdisciplinary teams should develop tailored interventions based on individual’s psychosocial and medical assessments. Reforms to the Medicare fee-for-service system have the potential to change financial incentives that currently favor hospitalization of older patients, the potential to avoid readmissions, and the potential to direct the savings to support interdisciplinary care transition interventions.