Dramatic reduction in 30-day readmissions through high-risk screening and two-phase interdisciplinary care

Mabel Labrada, Michael J. Mintzer, Chandana Karanam, Raquel Castellanos, Lorinda Cruz, Minh Hoang, Regina Wieger, Enrique Aguilar, Hermes Florez, Jorge G. Ruiz

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objectives Thirty-day readmissions are common, serious, and costly. Most important, often they are preventable. The purpose of this quality improvement study was to evaluate an interdisciplinary, two-phase intervention to reduce 30-day readmissions among high-risk medical patients. One or two high-risk patients were selected each weekday by a hospitalist using literature-based, locally tested criteria that included common medical illnesses, active psychiatric illness, and recent or recurrent hospital admissions. Methods Patients admitted to 1 of 5 medical hospitalist teams were selected to receive the intervention; patients admitted to the 4 remaining teams were used for comparison. The two-phase care coordination intervention consisted of a daily interdisciplinary team meeting for the selected high-risk patients and postdischarge interventions that included outpatient care coordination until the patients' first follow-up appointment. The care plan addressed medical/geriatric assessment, social stability, medication reconciliation, nutritional needs, care coordination including future appointments/testing, and community services. Eighty-five patients in the intervention group were compared with 84 patients from the comparison group using propensity score matching. Patient characteristics were similar at baseline. Results The intervention group demonstrated a reduction in 30-day readmissions by 52% (11 vs 23, P = 0.019). Length of stay was reduced: 5.5 days compared with 7.2 days (P = 0.258). Conclusions This intervention produced a significant reduction in 30-day readmissions for high-risk patients and a trend for shorter lengths of stay compared with similarly matched patients. Future research trials are needed to verify these results.

Original languageEnglish (US)
Pages (from-to)757-760
Number of pages4
JournalSouthern medical journal
Issue number12
StatePublished - Dec 1 2017
Externally publishedYes


  • 30-day readmissions
  • Acute care
  • High-risk medical patients
  • Interdisciplinary

ASJC Scopus subject areas

  • Medicine(all)


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