Observational studyBMJ open quality2023
Telehealth-based transitional care management programme to improve access to care.
Observational study in BMJ open quality, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT06830135 (A Multifaceted Telehealth Approach to Enhancing Glycemic Control and Reducing Readmissions in a Diverse Diabetic Population), which is not on this map. Cited by 10 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
A Multifaceted Telehealth Approach to Enhancing Glycemic Control and Reducing Readmissions in a Diverse Diabetic Population: A Randomized Control Trial
Who cites it
10 citing papers in PubMed.
- Implementing a RPM-enabled transitional care pathway for adults with poorly controlled diabetes: a quality improvement initiative.BMJ open quality · 2026Article
- Implementation of a Workplace-Based Telemedicine Simulation Program to Assess Clinical Skills After Transitions of Care.Journal of graduate medical education · 2026Article
- Article
- Patient and program level correlates of 30-day readmissions: a retrospective analysis of a transitional care program.BMC health services research · 2025Article
- Bridging the Gap in Chronic Disease Management: A Nursing Perspective on the Use of Predictive Tools and Telemedicine in the Hospital-Community Transition.Medicina (Kaunas, Lithuania) · 2025Review
- Article
- Improving Telehealth Transition of Care Programs Focused on Readmission Reduction.Journal of patient safety · 2025Article
- A Surgeon's Field Guide to Value-Based Specialty Care.Laryngoscope investigative otolaryngology · 2025Review
- Determinant factors of prolonged hospitalization in acute heart failure patients at Jimma Medical Center, Southwest Ethiopia.Scientific reports · 2025Observational
- Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study.BMC health services research · 2024Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning. LOCAL PROBLEM: Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission.
methodsThis is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort.
interventionsPatients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey.
results68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005).
conclusionsUsing a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.
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