SHM Converge Scientific Abstract ePoster Gallery-Virtual Transition of Care as a Health Equity Tool: Insights From a Hispanic Patient Cohort

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This retrospective study examined whether a hospitalist-led Virtual Transition of Care (VToC) clinic reduced 30-day unplanned readmissions among 8,143 Hispanic patients discharged from UC San Diego Health between September 2021 and September 2024. VToC offered virtual or phone follow-up within 7 days for high-risk patients (LACE score 50–75), focusing on symptom review, medication adherence, and outpatient follow-up coordination.<br /><br />Overall, patients who completed VToC had a lower 30-day readmission rate than those who did not attend VToC: 16.9% vs. 21.3% (OR 0.75, p=0.003). The benefit, however, was not equally distributed across subgroups.<br /><br />The strongest reductions were seen among English-preferring patients and privately insured patients. Non-English-preferring patients had a smaller, non-significant reduction (17.4% vs. 20.9%, p=0.135), suggesting that language-related barriers continue to limit the effectiveness of virtual follow-up. Similarly, patients with government insurance appeared to benefit less than those with private insurance, indicating that structural and social barriers may persist beyond a single post-discharge encounter.<br /><br />The authors note several features that may make VToC effective: early post-discharge contact, interpreter support, telephone visit options, medication review, and direct handoff to primary care. Still, they conclude that standardized virtual follow-up alone is not sufficient for the most vulnerable patients.<br /><br />Limitations include the single-center design, possible selection bias due to the need for phone or video access, and the use of insurance type and language preference as proxies for broader social complexity.<br /><br />Overall, the study supports VToC as a useful tool to reduce readmissions among Hispanic patients, but suggests that additional supports such as care navigation, social work, and community resources are needed to improve equity.

Asset Subtitle

Julia Y. Lu

Meta Tag

Author List Crystal W. Cene, Julia Y. Lu, Sarah F. Horman, Sutton Fox

Category Research

Concept Virtual Transitions of Care Clinic

Concept Hospital Readmission

Concept 30-Day Readmission

Concept Hispanic Patients

Concept Hospital Discharge

Distinguished Non-Finalist

Presenter Organization UC San Diego

Presenting Author Julia Y. Lu

Track Transitions of Care

Keywords

Virtual Transition of Care

readmission reduction

Hispanic patients

hospitalist-led clinic

post-discharge follow-up

30-day unplanned readmissions

language barriers

insurance disparities

medication adherence

care coordination

Virtual Transitions of Care Clinic

Hospital Readmission

30-Day Readmission

Hispanic Patients

Hospital Discharge