Targeted care navigation to reduce hospital readmissions in ‘at‐risk’ patients

Background Care navigation is commonly used to reduce preventable hospitalisation. The use of Electronic Health Record‐derived algorithms may enable better targeting of this intervention for greater impact. Aims To evaluate if community‐based Targeted Care Navigation, supported by an Electronic Health Record‐derived readmission risk algorithm, is associated with reduced rehospitalisation. Methods A propensity score matching cohort (5 comparison to 1 intervention cohort ratio) study was conducted in an 850‐bed Victorian public metropolitan health service, Australia, from May to November 2017. Admitted acute care patients with a non‐surgical condition, identified as at‐risk of hospital readmission using an Electronic Health Record‐derived readmission risk algorithm provide by the state health department, were eligible. Targeted Care Navigation involved telephone follow‐up support provided for 30 days post‐discharge by a registered nurse. The hazard ratio for hospital readmission was calculated at 30, 60 and 90 days post‐discharge using multivariable Cox Proportional Hazards regression. Results Sixty‐five recipients received care navigation and were matched to 262 people who did not receive care navigation. Excellent matching was achieved with standardised differences between groups being