Reducing hospital readmissions through primary care practice transformation

J Fam Pract. 2014 Feb;63(2):67-73.


Purpose: To assess the impact of a multicomponent intervention on 30-day hospital readmissions in a group of primary care practices that undertook practice transformation, compared with rates in usual-care practices that admitted patients to the same hospital service.

Methods: Four primary care clinics enhanced patient care coordination with care managers and inpatient care teams, and developed and used hospital readmission reports to monitor readmission rates. Patient readmissions to the hospital were analyzed over a 12-month period from May 2012 through April 2013, among patients who fell into 2 groups. Group 1 patients were those cared for by the primary care clinics that implemented transformation activities and who were admitted to the hospital associated with the practices. Group 2 patients were seen at clinics in the same catchment area that did not undertake any known practice redesign activities (usual care group).

Results: A total of 961 patients were included in analyses; 685 (71.3%) were in Group 1, and 276 (28.7%) were in Group 2. Readmissions among Group 1 patients decreased from 27% to 7.1% (P=.02), and readmissions in Group 2 were variable with a nonsignificant trend (P=.53). The unadjusted regression model that compared the interaction between Group 1 and Group 2 patients found a significant difference in readmissions (P=.05).

Conclusion: Developing a multicomponent intervention appears to have a significant impact on reducing hospital readmissions. Primary care groups seeking to reduce hospital readmissions should consider implementing similar processes.

MeSH terms

  • Adult
  • Female
  • Hospitals, University / organization & administration*
  • Hospitals, Urban / organization & administration*
  • Humans
  • Male
  • Middle Aged
  • Oregon
  • Organizational Innovation
  • Patient Care Team / organization & administration*
  • Patient Readmission / statistics & numerical data*
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians' / organization & administration*
  • Primary Health Care / organization & administration*