Attainment of Community-Based Goals Is Associated with Lower Risk of Hospital Readmission for Older Australians Accessing the Australian Transition Care Program

This study aimed to examine the 6-month hospital readmission rate for Transition Care Program (TCP) clients and its association with community goal attainment. This was a single-site retrospective cohort study of TCP clients admitted from 2014 to 2019. Goals were set at TCP entry and coded as goals ‘within the home’ or ‘in the community’. Hospital readmissions were tracked using electronic health records. Logistic regression, area under the curve, and number needed to treat were the primary analyses performed. Of 747 (66.8% female and 33.2% male) client episodes, 164 (22%) resulted in a hospital readmission. Clients who were not readmitted to hospital set and achieved a higher number of community-based goals (1.08 vs. 0.8, p = 0.01 and 0.8 vs. 0.6, p = 0.001). Utilising a logistic regression model, each additional community goal achieved was associated with a 30% reduction in risk of readmission to the hospital (OR: 0.69, 95%CI: 0.5–0.8; p = 0.002), adjusted for age, sex, MBI change, number of home goals achieved, hospital length of stay and number of comorbidities. Achieving community-based goals can reduce the risk of hospital readmission by 30% after adjusting for demographic and clinical variables.