Session Information
Session Title: Research Hub - Live Theater Research Spotlight: Practice Management, Leadership, and Quality Improvement
Session Time: None. Available on demand.
Disclosures: Megan E. Kennelly, MD: No financial relationships or conflicts of interest
Background and/or Objectives: To examine the association of patient follow up with the Transitional Care Clinic (TCC), a multi-disciplinary discharge clinic including physicians, pharmacists, behavioral health specialists and social workers, and potentially avoidable hospital readmissions (PAR) within 30 days in patients discharged from acute inpatient rehabilitation.
Design: Retrospective Cohort Study
Setting: Acute Inpatient Rehabilitation and Multi-Disciplinary Outpatient Clinic
Participants: Patients who underwent rehabilitation and were discharged to home between January 2021 and November 2021
Interventions: Not Applicable
Main Outcome Measures: 30-Day PAR
Results: Of the 1,005 patients discharged from acute rehabilitation from January 2021 to November 2021, 115 (11.4%) patients experienced 30-day PAR. Seventy-four patients were referred to TCC, of which 58 (78.4%) established care. There were lower rates of PAR for those who established care with TCC (6.90%) compared with the general rehabilitation population (11.72%), but this difference did not reach statistical significance (p = 0.31). Patients referred to TCC but who did not establish care had higher rate of PAR compared to patients that established with the clinic (31.25% vs 6.90%, p = 0.038).
Conclusions: Patients who established care with TCC, following acute inpatient rehabilitation had lower rates of 30-day PAR compared to the general rehabilitation patient population, however this did not reach statistical significance. In addition, patients who were referred to TCC but did not establish care had statistically significantly higher rates of 30-day PAR than the patients who did successfully establish care. Multi-disciplinary discharge clinics, like TCC, may help reduce 30-day PAR following acute rehabilitation for high-risk patients, however large multicenter studies are warranted.
Level of Evidence: Level III
To cite this abstract in AMA style:
Kennelly ME, Pinto SM, Rup N, Murphy S. The Effect of Multi-disciplinary Discharge Clinic on 30-day Avoidable Hospital Readmission Following Acute Inpatient Rehabilitation [abstract]. PM R. 2022; 14(S1)(suppl 1). https://pmrjabstracts.org/abstract/the-effect-of-multi-disciplinary-discharge-clinic-on-30-day-avoidable-hospital-readmission-following-acute-inpatient-rehabilitation/. Accessed May 17, 2025.« Back to AAPM&R Annual Assembly 2022
PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-effect-of-multi-disciplinary-discharge-clinic-on-30-day-avoidable-hospital-readmission-following-acute-inpatient-rehabilitation/