Aims: To examine the rate of 6 months hospital readmission for TCP clients and investigate the association between community goals attainment and hospital readmission
Methods:
This was a single site retrospective cohort study for TCP clients admitted from 2014 to 2019. Clients transferred to another TCP, sent back to hospital, or died during TCP admission were excluded. At TCP entry, goals setting completed by case manager using International Classification of Functioning and disability (ICF). A home goal was classified as anything that happened within the confines of the home boundary, whereas a community goal was anything that happened outside the home boundary. On discharge, goals were classified as fully, partially, or not attained. Hospital readmission in 6 months were established by linking TCP ‘transdata’ with QLD Health electronic medical records ieMR using UR number.
Results: Out of 1057 clients received TCP service, 747 (66.8%) female and (33.2%) male clients were linked to QLD health UR. Only 126 (22%) clients readmitted. Mean age, hospital length of stay, TCP length of stay, entry Modified Barthel Index (MBI) were not significantly different. The mean Exit MBI and MBI change were significantly lower for readmission clients (85.7 vs 90.5 P 0.001, and 11.5 vs 14.4 P 0.001 respectively). The mean number of community goals identified and attained by no readmission clients were higher than readmitted clients (1.08 vs 0.8 p 0.01, and 0.8 vs 0.6 p 0.001). In the binary logistic analysis, the number of community goals achieved (odd ratio 0.69 p 0.002 and 95% CI 0.5 to 0.8) were significant predictor of readmission adjusting for age, gender, MBI change, number of home goals achieved, hospital length of stay and number of comorbidities.
Conclusion:
Community goals setting, and attainment can reduce the risk of hospital readmission by 30%. It is possible that community goals leads to higher level of physical activity. Further study is required to examine the impact of motivating TCP clients to nominate community goals and investigate health outcomes in prospective interventional study.