Impact of a family medicine-based transitional care intervention on readmission and length of stay: a pilot study

Transitional care interventions, often led by hospital specialists, have mixed impact on reducing readmissions. Interventions led by family physicians may be more promising. The objective of this study was to evaluate the impact of a family-medicine-based intervention in reducing the incidence of emergency department (ED) visits, hospital readmissions and the length of stay (LOS) of older patients. A quasi-experimental pilot-study was conducted at a Family Medicine Group (FMG) in Montreal. Thirty-five patients discharged from the FMG-affiliated hospital between July 2014-2015 were compared to 68 historical controls discharged from the same hospital one year prior. Inclusion criteria were: 65+ years, rostered at FMG, high-risk of readmission; and discharged to home/senior residence. Patients’ charts were reviewed to determine a composite outcome of all-cause rates of acute hospital use (ED visit/hospital readmissions) and LOS at 30, 60, 90 and 180-days post-discharge. We found no statistically significant differences in acute hospital use rates between groups. LOS was statistically significantly shorter at 90- and 180-days for patients compared to controls: Incidence Rate Ratio (95% Confidence Interval) at 90-days: 0.66 (0.64-0.69) and at 180-days: 0.49 (0.43-0.55). Our study provides support to the impact of a family-medicine-based transitional care intervention in reducing the LOS of vulnerable older patients readmitted to hospital.