Accepted for/Published in: JMIR Medical Informatics
Date Submitted: Mar 5, 2025
Date Accepted: Aug 11, 2025
Virtual Transition of Care Clinics and Associated Readmission Rates: A Four-Year Study
ABSTRACT
Background:
Readmissions to the hospital are a significant burden on patients, providers, and healthcare systems, costing an estimated $17 billion annually. Timely follow-up within 7 days post-discharge is a protective measure to reduce readmissions but is constrained by access limitations. Transitions of care clinics have shown benefits in reducing unplanned readmissions, but physical space can be logistically and financially challenging. Virtual transitions of care (VToC) clinics present an opportunity to address these issues by improving care efficiency, reducing costs, and overcoming transportation barriers.
Objective:
At UC San Diego Health, we implemented a hospitalist-led VToC clinic focused on clinical management, medication reconciliation, primary care provider (PCP) repatriation, and specialty care navigation to reduce avoidable readmissions.
Methods:
Data was collected from the EHR using standard SQL queries. This included demographics (age grouped as <45, 45-64, ≥ 65; sex; race/ethnicity); VToC status (yes/no); PCP (UCSD or other); LACE+ score (<50, 50-70, >70); and 30-day all-cause readmission. Patient characteristics were analyzed by VToC status (yes vs no). VToC status of “no” indicates patients who were discharged from the Medicine service line to home and not seen in our clinic (because they did not meet eligibility criteria, or they could not be reached). Readmission rates were analyzed for VToC status and by LACE+ score.
Results:
A total of 2,314 patients were seen in the VToC clinic between September 2021 and September 2024. The 30-day readmission rate was 14.9% for VToC patients compared to 20.1% in the benchmark group (p<0.001). Regression analysis revealed that patients who did not participate in VToC had a higher odds ratio of readmission (OR=1.37; 95% CI=1.21-1.54; p<0.001). The greatest reduction was observed among patients with moderate readmission risk (LACE+ 50-75).
Conclusions:
This study demonstrates that VToC clinics are a feasible and effective tool for improving post-discharge care, reducing readmissions, and enhancing care coordination, while promoting the quadruple aim of improving health outcomes, patient experience, cost-efficiency, and care equity. Clinical Trial: n/a
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