Telehealth-based transitional care management programme to improve access to care.

Background: The 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.

Methods: This 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.