Readmissions to hospital in a frail older cohort receiving a community-based transitional care service.

Aims: To investigate frequency of and reasons for hospital readmission in a frail older cohort receiving a community-based, multidisciplinary, transitional care service.

Methods: A prospective cohort study with descriptive analysis of reasons for readmission in a cohort of frail older people discharged from hospital with the service. Measures of frailty, comorbidity, cognition, quality of life and function were recorded at discharge. Readmissions were recorded within three months after index discharge. Discharge summaries were reviewed and reasons for readmission categorised. Outcomes following readmission were recorded.

Results: Readmission rates were high (42%) in our cohort, despite the intervention. People readmitted had worse functional ability and a greater burden of comorbidities. Half of the readmissions were classified as being new, acute medical problems requiring inpatient treatment, and a quarter as exacerbations of chronic medical problems. Eighty-six percent of those readmitted were able to return home following their readmission.

Conclusions: Our study showed high readmission rates despite the community supports. This high readmission rate does not imply failure of the intervention as the majority of these were with new or acute medical problems requiring inpatient treatment which were not preventable. Most were able to recover and return to their own homes.