Efficacy of a Transition Clinic on Hospital Readmissions

Am J Med. 2018 Feb;131(2):178-184.e1. doi: 10.1016/j.amjmed.2017.08.037. Epub 2017 Sep 21.


Background: A primary care-staffed transition clinic is one potential strategy for reducing 30-day re-admissions for patients without an established primary care physician, but the effectiveness has not been studied. The objective was to test whether patients who completed a postdischarge transition clinic appointment were less likely to be readmitted within 30 days.

Methods: This retrospective cross-sectional study included adults with Medicare or Medicaid coverage who were discharged from general medicine units at Rush University Medical Center between October 2013 and October 2014. All patients had a follow-up appointment scheduled within 30 days of discharge in the transition clinic or with their primary care physician. A binary logistic regression model was constructed to test the relationship between 30-day readmission and follow-up appointment status, controlling for patient factors.

Results: The sample included 1149 patients with scheduled follow-up appointments (24% in the transition clinic and 76% with their primary care physician). After controlling for patient demographic characteristics and clinical factors, patients who did not complete a scheduled transition clinic appointment had approximately 3 times higher odds of readmission compared with patients who completed a transition clinic appointment (adjusted odds ratio, 2.80; P = .004). There was no significant difference in the likelihood of 30-day readmission between patients completing a transition clinic appointment and those who were scheduled with their primary care physician.

Conclusions: A primary care-staffed transition clinic is a promising strategy for providing access after a recent hospitalization and effectively managing the initial posthospital discharge needs of vulnerable populations.

Keywords: Care management; Postdischarge follow-up; Primary care; Transition clinic.

MeSH terms

  • Adult
  • Ambulatory Care Facilities*
  • Appointments and Schedules
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Medicaid
  • Medicare
  • Middle Aged
  • Patient Readmission*
  • Primary Health Care / methods*
  • Regression Analysis
  • Retrospective Studies
  • Risk Factors
  • Transitional Care*
  • United States