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Am J Manag Care. 2019 Jul 1;25(7):e219-e223.

Evolution of interdisciplinary geriatric transitions of care on readmission rates.

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Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202. Email:



To evaluate the effect of an interdisciplinary transitions of care (TOC) service on readmission rates in a geriatric population.


Single-center retrospective cohort study of adults 60 years or older discharged from an academic medical center.


From July 1, 2013, to February 21, 2016, a total of 4626 patients discharged from 1 hospital, including inpatient, emergency department, observation, and short-stay units, were included. Cases were scheduled for a TOC service with the interdisciplinary team. Controls received usual care at other sites. All-cause 14-, 30-, and 90-day readmission rates between propensity score-matched study groups were evaluated by intention-to-treat (ITT), per-protocol (PP), and as-treated methods.


During the study period, 513 patients were scheduled for at least 1 component of the TOC intervention (ITT group). Of those patients, 215 completed all scheduled visits (PP group). Readmission rate after 30 days demonstrated no difference in the ITT group compared with the control group (12.8% vs 10.7%; P = .215), although it was significantly lower in the PP group in comparison with the control group (12.8% vs 7.9%; P = .042).


An interdisciplinary team based in a patient-centered medical home improved readmission rates for all patients who completed the intervention (PP group).

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