Improving Patient Care Transitions at Rural and Urban Hospitals Through Risk Stratification

Rural and urban hospitals may face different challenges in care transition and care coordination. This chapter explored important care transition issues pertaining to rural and urban hospitals and demonstrated how data analytics and risk stratification methods could be applied to help identify patients who would be most likely to benefit from care transition interventions and inform decisions regarding resource allocation and intervention design. Two studies are included in this chapter. The first study examined emergency department (ED) utilization in critical access hospitals (CAHs), especially ED transfers to larger hospitals and non-emergent ED visits. The second study assessed hospital and community characteristics associated with 30-day all-cause hospital readmissions for general medicine patients. The findings identify the need to improve care coordination between local CAH, larger urban hospitals as well as primary care physicians to ensure proper follow-up care for patients discharged to their home community. Hospital and community characteristics are significantly associated with 30-day readmission and hence should be considered when adjusting readmission rates and setting financial penalties.