SHM Converge Scientific Abstract ePoster Gallery-Impact of Early Posthospitalization Follow-Up in a Transitional Medical Clinic on 30 Day Readmission Rate

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This study evaluated whether early follow-up in a Transitional Medical Clinic (TMC) reduced 30-day hospital readmissions among high-risk patients discharged from Mission Hospital. The TMC was designed to provide outpatient reassessment within one week of discharge, helping bridge inpatient and outpatient care.<br /><br />Researchers conducted a prospective, single-site cohort study of patients discharged between January 2017 and August 2025. Patients were divided into two groups: those who completed a TMC visit within one week of discharge (TMC group, n = 6,672) and those who were scheduled but did not attend or canceled (non-TMC group, n = 1,812). Eligible patients had PPO, HMO, or Medicare insurance and were identified by hospitalists as at high risk for readmission.<br /><br />Results showed that 628 of 6,672 patients in the TMC group were readmitted within 30 days, a rate of 9.4%. In contrast, 328 of 1,812 patients in the non-TMC group were readmitted, a rate of 18.1%. This difference was statistically significant (p < 0.001).<br /><br />The findings suggest that timely, structured follow-up through a transitional clinic is associated with fewer 30-day readmissions. Early post-discharge visits may help identify unresolved medical issues, reinforce discharge instructions, improve medication adherence, and connect patients with primary or specialty care. The study concludes that emphasizing discharge education and helping patients overcome barriers to TMC attendance may further improve outcomes and reduce hospital utilization.

Asset Subtitle

Param Desagani

Meta Tag

Author List Erik I. Finlayson, Loan T. Nguyen, Param Desagani, Pauneez Kasmai

Category Innovations

Concept 30-Day Readmission

Concept Transitional Medical Clinic

Concept Discharge Follow-up

Concept Prospective Cohort Study

Concept Continuity of Care

Distinguished Non-Finalist

Presenter Organization Pitzer College

Presenting Author Param Desagani

Track Transitions of Care

Keywords

Transitional Medical Clinic

30-day readmissions

post-discharge follow-up

hospital readmission reduction

high-risk patients

Mission Hospital

care transition

outpatient reassessment

discharge education

medication adherence

30-Day Readmission

Transitional Medical Clinic

Discharge Follow-up

Prospective Cohort Study

Continuity of Care