Original Article

Dramatic Reduction in 30-Day Readmissions Through High-Risk Screening and Two-Phase Interdisciplinary Care

Authors: Mabel Labrada, MD, Michael J. Mintzer, MD, Chandana Karanam, MD, Raquel Castellanos, MD, Lorinda Cruz, MD, Minh Hoang, MD, Regina Wieger, DNP, RN, Enrique Aguilar, MD, Hermes Florez, MD, Jorge G. Ruiz, MD


Objectives: Thirty-day readmissions are common, serious, and costly. Most important, often they are preventable. The purpose of this quality improvement study was to evaluate an interdisciplinary, two-phase intervention to reduce 30-day readmissions among high-risk medical patients. One or two high-risk patients were selected each weekday by a hospitalist using literature-based, locally tested criteria that included common medical illnesses, active psychiatric illness, and recent or recurrent hospital admissions.

Methods: Patients admitted to 1 of 5 medical hospitalist teams were selected to receive the intervention; patients admitted to the 4 remaining teams were used for comparison. The two-phase care coordination intervention consisted of a daily interdisciplinary team meeting for the selected high-risk patients and postdischarge interventions that included outpatient care coordination until the patients’ first follow-up appointment. The care plan addressed medical/geriatric assessment, social stability, medication reconciliation, nutritional needs, care coordination including future appointments/testing, and community services. Eighty-five patients in the intervention group were compared with 84 patients from the comparison group using propensity score matching. Patient characteristics were similar at baseline.

Results: The intervention group demonstrated a reduction in 30-day readmissions by 52% (11 vs 23, P = 0.019). Length of stay was reduced: 5.5 days compared with 7.2 days (P = 0.258).

Conclusions: This intervention produced a significant reduction in 30-day readmissions for high-risk patients and a trend for shorter lengths of stay compared with similarly matched patients. Future research trials are needed to verify these results.

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