{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,1]],"date-time":"2026-03-01T05:27:34Z","timestamp":1772342854196,"version":"3.50.1"},"reference-count":28,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2021,8,18]],"date-time":"2021-08-18T00:00:00Z","timestamp":1629244800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["UL1TR002537"],"award-info":[{"award-number":["UL1TR002537"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["shmpublications.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Hospital Medicine"],"published-print":{"date-parts":[[2021,10]]},"abstract":"<jats:sec><jats:title>BACKGROUND\/OBJECTIVE<\/jats:title><jats:p>Hospital readmissions in the United States, especially in patients at high\u2010risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions\u2010of\u2010care clinic (TOCC) to reduce 30\u2010day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans.<\/jats:p><\/jats:sec><jats:sec><jats:title>METHODS<\/jats:title><jats:p>In this quality improvement initiative we conducted a pre\u2010post study evaluating clinical outcomes in adult patients at high risk for 30\u2010day readmission (Care Assessment Needs score &gt; 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in\u2010person or virtual follow\u2010up to high\u2010risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow\u2010up impacted the monthly 30\u2010day patient readmission rate.<\/jats:p><\/jats:sec><jats:sec><jats:title>RESULTS<\/jats:title><jats:p>The TOCC resulted in a 19.2% relative reduction in 30\u2010day readmission rates in the 12\u2010month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, <jats:italic>P<\/jats:italic> = .04). Virtual visits were more popular than in\u2010person visits among both urban and rural veterans. There was no difference in outcomes between these two follow\u2010up options, and both groups had reduced readmission rates compared to non\u2010TOCC follow\u2010up.<\/jats:p><\/jats:sec><jats:sec><jats:title>CONCLUSIONS<\/jats:title><jats:p>A multidisciplinary TOCC within the ICVA featuring both virtual and in\u2010person visits reduced the 30\u2010day readmission rate. This reduction was particularly notable among patients with congestive heart failure. <jats:italic>Journal of Hospital Medicine<\/jats:italic> 2021;16:583\u2010588.<\/jats:p><\/jats:sec>","DOI":"10.12788\/jhm.3659","type":"journal-article","created":{"date-parts":[[2021,8,23]],"date-time":"2021-08-23T15:19:45Z","timestamp":1629731985000},"page":"583-588","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["An Initiative to Improve 30\u2010Day Readmission Rates Using a Transitions\u2010of\u2010Care Clinic Among a Mixed Urban and Rural Veteran Population"],"prefix":"10.1002","volume":"16","author":[{"given":"Benjamin R","family":"Griffin","sequence":"first","affiliation":[{"name":"Iowa City Veterans Affairs Health Care System Iowa City Iowa"},{"name":"Department of Medicine University of Iowa Carver College of Medicine Iowa City 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