Improving Post-Hospital Care for Patients with Complex Medical and Social Needs: Evaluation of a Transitional Care Clinic

The Hospital Readmissions Reduction Program (HRRP), created in 2010, was a sweeping national effort to reduce preventable readmissions by linking them to hospital payment. However, the law’s effects at the aggregate level have been mixed. Aiming to find a path forward on readmissions, this thesis studies one Arizona hospital’s approach to improving post-hospital care through developing a multidisciplinary transitional care clinic. It describes the clinic’s model of addressing the needs of its largely low-income and chronically ill patient population and analyzes data to evaluate this model. Patients who attended the clinic were found to have a significantly lower readmission rate over 30 and 90 days compared to patients who enrolled but did not attend. This effect held after accounting for several other factors that predict readmission. This thesis concludes by discussing how lessons from this hospital’s experience could be applied to other institutions and detailing areas for further study