BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans.

METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate.

RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up.

CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

背景/目标：美国的医院再入院，尤其是高危患者，每年花费超过 170 亿美元。尽管护理转变是一个重要的研究领域，但关于其疗效的数据有限，尤其是在农村患者中。在这项研究中，我们描述了一个新的医疗过渡诊所 (TOCC)，以减少退伍军人健康管理局环境中的 30 天再入院，该环境为大部分农村退伍军人提供服务。

方法：在这项质量改进计划中，我们进行了一项事前研究，评估从爱荷华市退伍军人事务部 (ICVA) 医疗保健系统出院的 30 天再入院高风险（护理评估需求评分 > 85）成年患者的临床结果。 2017 年至 2020 年。ICVA 为爱荷华州东部、伊利诺伊州西部和密苏里州北部 50 个县的 184,000 名退伍军人提供服务，其中 60% 以上的患者居住在农村地区。我们实施了一项多学科 TOCC，以便在出院后为高危退伍军人提供面对面或虚拟随访。本研究的主要目的是评估 TOCC 随访如何影响每月 30 天的患者再入院率。

结果：与实施前相比，TOCC 导致实施后 12 个月的 30 天再入院率相对降低 19.2%（9.2% 对 11.4%，P = .04）。在城市和农村退伍军人中，虚拟访问比亲自访问更受欢迎。这两种随访方案的结果没有差异，与非 TOCC 随访相比，两组的再入院率均有所降低。

结论： ICVA 内的多学科 TOCC 以虚拟和面对面访问为特色，降低了 30 天的再入院率。这种减少在充血性心力衰竭患者中尤为显着。