Geriatric Transitional Care and Readmissions Review

• Transitional care is a growing area of health care.
• A transitional care program was developed.
• Telephone calls and home visits for 30 days after discharge.
• Several themes identified with hospital readmissions.
• Rapid follow-up is essential.

Geriatric patients are a highly vulnerable population and are at increased risk for hospital admission and readmission. A university hospital implemented the Geriatric Transitional Care program, aimed at improving quality of care and reducing 30-day hospital readmission rates. Enrolled patients received telephone calls, and, if there was high risk for readmission, home visits from a nurse practitioner. Twenty-six (6.6%) inpatient-to-inpatient readmissions occurred, which was a 48% reduction from the hospital-wide readmission rate. Causes of readmissions fell into 6 categories. Transitional care can reduce frequency, serve as a point of contact, and monitor discharge follow-up.