The impact of Kaua'i Care Transition Intervention on hospital readmission rates.

OBJECTIVES To evaluate the effects of Kaua'i Care Transition Intervention (KCTI), a patient-centered intervention program, on reducing hospital readmission rates among patients 60 years or older. STUDY DESIGN A prospective quasi-experimental prepost design. METHODS Hospital admissions data for the year 2010 (January 1 to December 31) served as the baseline data and were used to identify patients at risk of hospital readmission. KCTI was implemented over a 12-month period from April 1, 2012, to March 31, 2013, and 30-day, 60-day, and 1-year readmission rates were assessed for both the intervention and baseline periods. The impact of the intervention was examined by a logistic regression model, controlling for possible patient population differences. RESULTS During the intervention period, a total of 269 patients 60 years or older were admitted to the hospital, of which, 58 were referred to the KCTI program. Logistic regression controlling for patients' primary health insurance, discharge sites, and certain admitting diagnoses (eg, arrhythmias, cellulitis, chronic obstructive pulmonary disease) found that the intervention reduced the 30-day readmission rate by two-thirds (odds ratio [OR], 0.34; P = .003). Readmission rates within 60 days (OR, 0.42; P < .01) and within a year (OR, 0.48; P < .001) during the intervention period were less than half of the baseline rates. CONCLUSIONS By selecting patients with identified risk factors, then empowering and educating them with the intervention program, this study was successful in reducing hospital readmission rates. This study also demonstrated the value of carefully selecting patients for intervention programs.