Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions.

Background: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions.

Methods: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components.