Transitional Care Program and Patient Correlates of 30-Day Readmissions in Individuals With Congestive Heart Failure

Authors: Karim AlKhalidi, Elizabeth Middleton, Farrukh Jafri, Chava Pollak

SUNY Campus: Purchase College

Presentation Type: Poster

Location: UU 108

Presentation #: 82

Timeslot: Session C 1:45-2:45 PM

Abstract: Background: Transitional care programs represent hospital-centric strategies that support patients during the 30-day window following discharge, where the risk of readmission is heightened. The primary purpose of this study was to identify what patient and program-level factors were linked to 30-day readmissions in patients hospitalized with congestive heart failure (CHF). Transitional care programs represent dynamic systems, from the number and type of strategies implemented to the makeup of the patient population. Understanding the conditions linked to 30-day readmissions is critical for improving patient outcomes and guiding program development. Methods: Adults (Mean age 78.5, 50.4% female, 67.9% White, 21% Black) hospitalized at a community-based hospital in White Plains, NY from January 1st, 2023 to December 31st, 2023 and discharged to home were considered in this retrospective study. A logistic regression analysis was performed. Results: Multimorbidity, multiple readmissions, and 7-day ambulatory follow-up appointments were significantly linked to 30-day readmissions. Individuals with 7-day follow-up appointments had 62% lower odds of 30-day readmission (p = 0.003). Individuals with multimorbidity and multiple readmissions had 1.27 times and 5.98 times greater odds of readmission (p = 0.002 and p < 0.001, respectively). Conclusions: Transitional care strategies, namely 7-day ambulatory follow-up, appear to play important roles for CHF patients during their transitional period and may be best targeted towards patients with advanced age, multimorbidity, or with multiple readmissions. Further research is needed to better understand barriers and facilitators of program implementation and which patient and program factors are causally linked with 30-day readmissions.