Table 2.
Description of Study Population (N = 35,174 discharges)
| Treatment Group | |||||||
|---|---|---|---|---|---|---|---|
| Overall (N = 35,174) | Home Visit (N = 7468) | Other Transitional Care (N = 27,706) | |||||
| N | (%) | N | (%) | N | (%) | P1 | |
| Client Age in Years, Mean (SD) | 37.98 | (18.78) | 44.13 | (17.16) | 36.33 | (18.86) | <0.001 |
| Female Client | 20,938 | (59.53) | 4801 | (64.29) | 16,137 | (58.24) | <0.001 |
| Client Race | |||||||
| White | 16,904 | (48.06) | 3393 | (45.43) | 13,511 | (48.77) | <0.001 |
| Black | 15,031 | (42.73) | 3551 | (47.55) | 11,480 | (41.44) | |
| Other | 3239 | (9.21) | 524 | (7.02) | 2715 | (9.80) | |
| Hispanic Client | 1278 | (3.63) | 260 | (3.48) | 1018 | (3.67) | 0.681 |
| Client Language Not English | 697 | (1.98) | 142 | (1.90) | 555 | (2.00) | 0.943 |
| Readmission Risk Strata based on Clinical Risk Group | |||||||
| 0–<10% | 3454 | (9.82) | 548 | (7.34) | 2906 | (10.49) | <0.001 |
| 10–<20% | 7567 | (21.51) | 1302 | (17.43) | 6265 | (22.61) | |
| 20–<30% | 6827 | (19.41) | 1476 | (19.76) | 5351 | (19.31) | |
| 30–<40% | 5957 | (16.94) | 1333 | (17.85) | 4624 | (16.69) | |
| 40–<50% | 4809 | (13.67) | 1065 | (14.26) | 3744 | (13.51) | |
| ≥50% | 6560 | (18.65) | 1744 | (23.35) | 4816 | (17.38) | |
| Chronic Medication Fills per Month of Medicaid Eligibility in Prior year | |||||||
| No chronic meds | 2355 | (6.70) | 371 | (4.97) | 1984 | (7.16) | <0.001 |
| <1 chronic med/month | 6689 | (19.02) | 1024 | (13.71) | 5665 | (20.45) | |
| 1–2 chronic meds/month | 5574 | (15.85) | 974 | (13.04) | 4600 | (16.60) | |
| >2 chronic meds/month | 20,556 | (58.44) | 5099 | (68.28) | 15,457 | (55.79) | |
| # of Acute Medication Fills in Past Year | |||||||
| None | 2186 | (6.21) | 396 | (5.30) | 1790 | (6.46) | <.001 |
| 1–6 | 6932 | (19.71) | 1330 | (17.81) | 5602 | (20.22) | |
| 7–20 | 10,568 | (30.04) | 2153 | (28.83) | 8415 | (30.37) | |
| ≥21 | 15,488 | (44.03) | 3589 | (48.06) | 11,899 | (42.95) | |
| Number of Acute Medications Filled in Past Year, Mean (SD) | 23.90 | (23.89) | 26.23 | (25.42) | 23.27 | (23.42) | <.001 |
| Mental Health Diagnosis in Past 2 Years | 12,293 | (34.95) | 2425 | (32.47) | 9868 | (35.62) | <0.001 |
| Substance Abuse Diagnosis in Past 2 Years | 10,996 | (31.26) | 2258 | (30.24) | 8738 | (31.54) | 0.056 |
| # Outpatient Providers in Past Year | |||||||
| 0–2 | 220 | (0.63) | 42 | (0.56) | 178 | (0.64) | <.001 |
| 3–7 | 4816 | (13.69) | 893 | (11.96) | 3923 | (14.16) | |
| 8–11 | 8474 | (24.09) | 1717 | (22.99) | 6757 | (24.39) | |
| 12–15 | 8287 | (23.56) | 1801 | (24.12) | 6486 | (23.41) | |
| ≥16 | 13,377 | (38.03) | 3015 | (40.37) | 10,362 | (37.40) | |
| # Outpatient Providers in Past Year, Mean(SD) | 14.49 | (7.05) | 14.86 | (6.94) | 14.39 | (7.08) | <.001 |
| # of Inpatient Admissions in Past Year | |||||||
| 0 | 17,827 | (50.68) | 3608 | (48.31) | 14,219 | (51.32) | <.001 |
| 1 | 7715 | (21.93) | 1779 | (23.82) | 5936 | (21.42) | |
| 2 | 3647 | (10.37) | 816 | (10.93) | 2831 | (10.22) | |
| ≥3 | 5985 | (17.02) | 1265 | (16.94) | 4720 | (17.04) | |
| # of Inpatient Visits in Past Year, Mean (SD) | 1.39 | (2.95) | 1.31 | (2.33) | 1.41 | (3.10) | 0.004 |
| # of ED Visits in Past Year | |||||||
| 0 | 8953 | (25.45) | 2016 | (27.00) | 6937 | (25.04) | 0.002 |
| 1 | 7105 | (20.20) | 1510 | (20.22) | 5595 | (20.19) | |
| 2–3 | 8582 | (24.40) | 1850 | (24.77) | 6732 | (24.30) | |
| ≥4 | 10,534 | (29.95) | 2092 | (28.01) | 8442 | (30.47) | |
| # of ED Visits in Past Year, Mean (SD) | 3.55 | (6.17) | 3.13 | (5.05) | 3.66 | (6.44) | <.001 |
| Length of Index Admission in Days, Mean (SD) | 6.15 | (9.79) | 5.88 | (7.93) | 6.23 | (10.24) | 0.004 |
| Surgical Index Hospitalization | 6733 | (19.15) | 1409 | (18.87) | 5324 | (19.22) | 0.544 |
| Discharged on Saturday/Sunday | 6972 | (19.82) | 1503 | (20.13) | 5469 | (19.74) | 0.614 |
| Discharged with Home Health Services | 4889 | (13.90) | 1370 | (18.34) | 3519 | (12.70) | <.001 |
| Population Size of Client County | |||||||
| <100K | 12,745 | (36.23) | 2915 | (39.03) | 9830 | (35.48) | <.001 |
| 100K–<200K | 7242 | (20.59) | 1093 | (14.64) | 6149 | (22.19) | |
| >200K | 15,187 | (43.18) | 3460 | (46.33) | 11,727 | (42.33) | |
| Size of Hospital | |||||||
| <100 beds | 2236 | (6.36) | 507 | (6.79) | 1729 | (6.24) | <.001 |
| 100–499 beds | 16,130 | (45.86) | 3056 | (40.92) | 13,074 | (47.19) | |
| ≥500 | 16,808 | (47.79) | 3905 | (52.29) | 12,903 | (46.57) | |
| Readmission within 90 days | 9794 | (27.84) | 1897 | (25.40) | 7897 | (28.50) | <.001 |
| Readmission within 30 days | 4942 | (14.05) | 739 | (9.90) | 4203 | (15.17) | <.001 |
ED, emergency department; SD, standard deviation