Skip to main navigation menu Skip to main content Skip to site footer

Research Article

Vol. 18 No. 1 (2020)

Impact of a family medicine-based transitional care intervention on readmission and length of stay: a pilot study

July 22, 2019


Transitional care interventions, often led by hospital specialists, have mixed impact on reducing readmissions. Interventions led by family physicians may be more promising. The objective of this study was to evaluate the impact of a family-medicine-based intervention in reducing the incidence of emergency department (ED) visits, hospital readmissions and the length of stay (LOS) of older patients. A quasi-experimental pilot-study was conducted at a Family Medicine Group (FMG) in Montreal. Thirty-five patients discharged from the FMG-affiliated hospital between July 2014-2015 were compared to 68 historical controls discharged from the same hospital one year prior. Inclusion criteria were: 65+ years, rostered at FMG, high-risk of readmission; and discharged to home/senior residence. Patients’ charts were reviewed to determine a composite outcome of all-cause rates of acute hospital use (ED visit/hospital readmissions) and LOS at 30, 60, 90 and 180-days post-discharge. We found no statistically significant differences in acute hospital use rates between groups. LOS was statistically significantly shorter at 90- and 180-days for patients compared to controls: Incidence Rate Ratio (95% Confidence Interval) at 90-days: 0.66 (0.64-0.69) and at 180-days: 0.49 (0.43-0.55). Our study provides support to the impact of a family-medicine-based transitional care intervention in reducing the LOS of vulnerable older patients readmitted to hospital.


  1. Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51(4):556-7.
  2. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-84.
  3. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002;39(3):238-47.
  4. Lewis G. Predictive modeling in action: how ‘virtual wards’ help high-risk patients receive hospital care at home. Issues in International Health Policy, Commonwealth Fund pub 2010;1430(94):1-16.
  5. Lewis G, Georghiou T, Steventon A, Viathianathan R, Chitnis X, Billings J, et al. Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. Final report. National Institute for Health Research Service Delivery and Organisation programme. Southampton: National Institute for Health Research; 2013.
  6. Le Berre M, Maimon G, Sourial N, Guériton M, Vedel I. Impact of transitional care services for chronically ill older patients: a systematic evidence review. J Am Geriatr Soc. 2017;65(7):1597-608.
  7. Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158(5_Part_2):433-40.
  8. Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O'Neil M, et al. VA Evidence-based Synthesis Program Reports. Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration. Washington (DC): Department of Veterans Affairs (US); 2015.
  9. Lewis G, Vaithianathan R, Wright L, Brice MR, Lovell P, Rankin S, et al. Integrating care for high-risk patients in England using the virtual ward model: lessons in the process of care integration from three case sites. Int J Integr Care. 2013;13:e046.
  10. Verhaegh KJ, MacNeil-Vroomen JL, Eslami S, Geerlings SE, de Rooij SE, Buurman BM. Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Aff (Millwood). 2014;33(9):1531-9.
  11. Low LL, Tan SY, Ng MJ, Tay WY, Ng LB, Balasubramaniam K, et al. Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: A Randomized Controlled Trial. PLoS One. 2017;12(1):e0168757.
  12. Dhalla IA, O’Brien T, Morra D, Thorpe KE, Wong BM, Mehta R, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12.
  13. Lewis G. Case study: virtual wards at Croydon primary care trust. London: The King's Fund. 2006.
  14. Deacon M. Caring for people in the 'virtual ward': the practical ramifications for acute nursing work. J Psychiatr Ment Health Nurs. 2003;10(4):465-71.
  15. Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, et al. Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q. 2012;90(2):311-46.
  16. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182(6):551-7.
  17. Lewis C, Moore Z, Doyle F, Martin A, Patton D, Nugent LE. A community virtual ward model to support older persons with complex health care and social care needs. Clin Interv Aging. 2017;12:985.
  18. Bourgeois FC, Olson KL, Mandl KD. Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Arch Intern Med. 2010;170(22):1989-95.
  19. Gagnon J, Gonzalez Reyes A, Vedel I, Ladores M, Vriniotis G, Arsenault-Lapierre G, et al., editors. Insights following the implementation of a family medicine based virtual ward. 44th NAPCRG annual meeting; 2016 November, 12-16; Colorado Springs, USA.


Download data is not yet available.