Journal of General Internal Medicine

, Volume 33, Issue 5, pp 621–627 | Cite as

Improving Outcomes After Hospitalization: A Prospective Observational Multicenter Evaluation of Care Coordination Strategies for Reducing 30-Day Readmissions to Maryland Hospitals

  • Erik H. Hoyer
  • Daniel J. Brotman
  • Ariella Apfel
  • Curtis Leung
  • Romsai T. Boonyasai
  • Melissa Richardson
  • Diane Lepley
  • Amy Deutschendorf
Original Research



Patients frequently experience suboptimal transitions from the hospital to the community, which can increase the likelihood of readmission. It is not known which care coordination services can lead to improvements in readmission rates.


To evaluate the effects of two care coordination interventions on 30-day readmission rates.


Prospective multicenter observational study of hospitalized patients eligible for two care coordination services between January 1, 2013, and October 31, 2015. Readmission rates were compared for patients who received each care coordination intervention versus those who did not using multivariable generalized estimating equation logistic regression models.


A total of 25,628 patients hospitalized in medicine, neurosciences, or surgical sciences units.


Patients discharged home and deemed to be at high risk for readmission were assigned a nurse Transition Guide (TG) for 30 days post-discharge. All other patients were assigned the Patient Access Line (PAL) intervention, which provided a post-discharge phone call from a registered nurse.


Two large academic hospitals in Baltimore, MD.

Main Measures

Thirty-day all-cause readmission to any Maryland hospital.

Key Results

Among all patients, 14.2% (2409/16,993) of those referred for the PAL intervention and 22.8% (1973/8635) of those referred for the TG intervention were readmitted. PAL-referred patients who did not receive the intervention had an adjusted odds ratio (aOR) for readmission of 1.27 (95% confidence interval [95% CI] 1.12–1.44, p < 0.001) compared with patients who did. TG-referred patients who did not receive the TG intervention had an aOR of 1.83 (95% CI 1.60–2.10, p < 0.001) compared with patients who received the intervention. Younger age, male sex, having more comorbidities, and being discharged from a medicine unit were associated with not receiving an assigned intervention. These characteristics were also associated with higher readmission rates.


PAL and TG care coordination interventions were associated with lower rates of 30-day readmission. Our findings underscore the importance of determining the appropriate intervention for the hardest-to-reach patients, who are also at the highest risk of being readmitted.



We thank Albert W. Wu, MD, MPH, for his review and comments during the preparation of this manuscript.


The project described was supported by grant number 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented was conducted by the awardee. Results may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.

Compliance with Ethical Standards

Conflict of Interest

All authors declare that they have no conflict of interest.


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Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Erik H. Hoyer
    • 1
    • 2
  • Daniel J. Brotman
    • 2
  • Ariella Apfel
    • 2
  • Curtis Leung
    • 3
  • Romsai T. Boonyasai
    • 2
  • Melissa Richardson
    • 3
  • Diane Lepley
    • 3
  • Amy Deutschendorf
    • 3
  1. 1.Department of Physical Medicine and Rehabilitation Johns Hopkins UniversityBaltimoreUSA
  2. 2.Division of General Internal MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of Care Coordination and Clinical Resource ManagementJohns Hopkins Health SystemBaltimoreUSA

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