Preventing 30 Day Hospital Readmissions Through Predictor Identification

Introduction: Safe Transitions for Elderly Patients (STEP) is an in-home transitional care service for Medicaid eligible adults aged 50 and older with the goal of ameliorating the CMMS national average rate 21.6% (2013) of patients’ readmission to the hospital within 30 days of discharge. The purpose of the project is to identify potential modifiable clinical and non-clinical factors that will improve patient safety and reduce rehospitalization rates for this vulnerable population. Methods: The study design is a retrospective cohort study of data collected from 498 patients age 50 and older that were enrolled in the STEP program. Exclusion criteria from the original data includes all patients without a BMI assessment, a risk stratification, a transportation assessment, a living assessment, and anyone who was not asked about their primary care provider (PCP). The remaining data was analyzed with respect to readmission status, medical conditions, and risk stratification classification. Comparisons were analyzed using SPSS statistical software including chi-square testing and odds ratio analysis. Results: The readmission rate for the patients included in this study 19.5%. The odds ratio revealed that age greater than 65 (2.02, 95% CI 1.23-3.24), seven to eleven diagnoses at readmission (1.75, 95% CI 1.12-2.74), High Risk Stratification (2.81, 95% CI 1.70-4.63), CHF (2.00, 95% CI 1.22-3.28), and COPD (1.74, 95% CI 1.08-2.79) were each individually associated with higher odds of readmission within 30 days. Living alone was associated with lower rate of readmission within 30 days (0.53, 95% CI 0.30-0.93). Data collected that that proved to be statistically not significant included pain scale rating greater than 6, not having a primary care provider, limited transportation, diabetes mellitus type 2, obesity, and hypertension. Conclusions: The individual factors—age greater than 65, High Risk Stratification, CHF, and COPD—are significant predictors of readmission within 30 days post discharge within this population. Knowing about these factors will help design transition of care programs that target this high-risk population.