Patient and Program Level Correlates of 30-day Readmissions: A Retrospective Analysis of a Transitional Care Program

Background: Hospital readmissions present a substantial burden to patients and healthcare systems in terms of outcomes and financial penalties. The primary purpose of this study was to identify patient and program-specific factors linked to 30-day readmissions in patients with congestive health failure (CHF) enrolled in a hospital-based transitional care program. Methods: We performed a retrospective analysis of electronic health record (EHR) data and program records from 343 community-dwelling adults (median age 81, 50.4% female, 67.9% White, 21% Black) with congestive heart failure (CHF) who were discharged from a community hospital in Westchester County, NY between January 1, 2023 and December 31, 2023. Our outcome of interest was 30-day hospital readmission. Logistic regression models were used to examine patient and program-specific predictors of 30-day readmission. Results: Of 343 individuals, 19.8% were readmitted within 30 days. Each point increase in comorbidities was associated with 35% greater odds of readmission (p<0.001, CI 1.17, 1.57). Those with ambulatory follow-up within 7 days had 62% lower odds of 30-day readmission compared to those without 7-day follow-up (p=0.001, CI 0.2, 0.71). Those who interacted with the TCM team had an 81% lower risk of readmission compared to those who were not reached by the team. Conclusion: Comprehensive transitional care programs have potential to reduce unnecessary hospital readmissions in patients with CHF. Touch points are key for patients discharged from the hospital following a CHF admission, whether via a transitional care program, ambulatory providers, or (ideally) both regardless of how soon after discharge this occurs.