Attainment of Community-Based Goals Is Associated with Lower Risk of Hospital Readmission for Clients in the Australian Transition Care Program (TCP)

This study examined the 6-month hospital readmission rate for Transition Care Program clients and its association with community goal attainment. This was a single-site retrospective cohort study of TCP clients admitted from 2014 to 2019. Goals were set at TCP entry, classified as home- or community-based, and mapped to the International Classification of Functioning and Disability. Hospital readmissions were tracked using QLD Health records. Of 1057 clients receiving TCP service, 747 (66.8% female and 33.2% male) client episodes were linked to a QLD Unique Record Number. Only 164 (22%) clients were readmitted to hospital. The mean exit Modified Barthel Index (MBI) and MBI change were significantly lower for readmitted clients (85.7 vs 90.5, p=0.001 and 11.5 vs 14.4, p=0.005). Clients who were not readmitted to hospital set and achieved a higher number of community-based goals (1.08 vs 0.8, p=0.01 and 0.8 vs 0.6, p=0.001). Utilising a logistic regression model, each additional community goal achieved was associated with a 30% reduction in risk of readmission to hospital (OR: 0.69, 95%CI: 0.5-0.8; p=0.002), adjusted for age, sex, MBI change, number of home goals achieved, hospital length of stay and number of comorbidities. Achieving community-based goals can reduce the risk of hospital readmission by 30% after adjusting for demographic and clinical variables.