image: Researchers at the University of California San Diego School of Medicine found that a UC San Diego Health telemedicine clinic for high-risk patients to be seen immediately after leaving the hospital resulted in less readmissions.
Credit: Kyle Dykes, UC San Diego Health
In a recent study, researchers at the University of California San Diego School of Medicine found that a UC San Diego Health telemedicine clinic for high-risk patients to be seen immediately after leaving the hospital resulted in less readmissions.
The study results, published in the Sept. 23, 2025 online edition of JMIR Medical Informatics, found the overall 30-day readmission rate for patients seen in the virtual transition of care clinic was 14.9%, compared to 20.1% for the benchmark group.
“With our virtual transition of care clinic, we are providing patients with the right care, at the right place, at the right time. With the convenience of meeting virtually, we’re able to reach patients much more efficiently,” said Sarah Horman, MD, lead author of the study and professor of medicine at UC San Diego School of Medicine.
Across the nation, hospital readmissions pose a significant burden on patients, health care providers and medical systems, with an estimated annual cost of $17 billion. To address this challenge, a team of physicians and executive leadership at UC San Diego Health implemented the virtual clinic to support clinical management and specialty care navigation for patients being discharged in the health system.
Launched in 2021, the virtual transition of care clinic is supported by 12 hospitalists, two medical assistants, one pharmacist and an on-demand interpreter service. Visits were occasionally converted to telephone encounters when patients faced technical challenges.
During the study, a standardized hand-off was routed to the patient’s primary care provider and relevant specialists that summarized the reason for hospitalization, follow-up care and timing recommendations. For patients that experienced issues post-discharge, expedited calls were made from the virtual care team to the patient’s primary care provider to ensure the patient was seen in-person quicker.
“When telemedicine first began, there was concern it would further increase health disparities, especially in vulnerable patient groups. However, through our research, we have found the opposite as the virtual clinic reaches patients more effectively,” said Horman, hospitalist and affiliate faculty at the Joan and Irwin Jacobs Center for Health Innovation at UC San Diego Health. “For example, many patients do not have access to transportation for in-person follow-up visits, so they will often skip them altogether, resulting in an increased risk of hospital readmission. For patients who did not have access to video visits, we coordinated telephone calls instead. In total, the no-show rate for these follow-up visits was less than 5%.”
According to Horman, the clinic addresses three main themes that are paramount in a critical care setting: access to and availability of medications, patient and caregiver understanding in the care plan, and proper navigation with primary care and/or specialty care programs.
“Our goal is to hardwire this linkage in the care chain between the hospital team and primary care in order to help expedite support during that very sensitive, post-hospital period of time,” said Horman. “As a result, patient outcomes are improving while they recover at home and hospitals have capacity to take care of the next patient in need of critical care.”
The virtual transition of care clinic and corresponding study involved more than 25,000 participants cared for at UC San Diego Health from Sept. 1, 2021 to Sept. 17, 2024. Of the participants, 2,314 were seen in the virtual clinic and 23,129 had standard follow-up care as the study’s benchmark group.
The typical time a patient is seen by their primary care physician after a hospital stay is two to four weeks. Through this clinic, patients who are considered moderate or high risk in terms of health outcomes are seen within a week after discharge.
“Our clinic is a one-time, virtual visit with a patient immediately after their hospital stay to ensure we’re doing all we can to mitigate risk,” added Horman.
The study relied on the LACE+ index to identify patients at high risk for hospital readmission or complications after discharge. LACE stands for length of stay, acuity of admission, comorbidity and emergency department visits, and considers certain factors such underlying health conditions, a patient’s age or sex and previous admissions.
“The use of LACE+ underscores the importance of data-driven and patient-centric strategies in enhancing patient outcomes,” said Horman. “By using this tool, we were able to target follow-up care to those most likely to benefit. This approach helped improve care transitions and reduce avoidable hospital visits.”
Horman adds that the results from this initiative are promising as health systems work toward improving population health, enhancing the care experience, reducing cost and advancing care equity.
The virtual transition of care clinic at UC San Diego Health is ongoing and currently seeing patients cared for at Hillcrest and Jacobs Medical Centers, with plans to launch at East Campus Medical Center soon.
Co-authors of the study include Milla Kviatkovsky, Edward Castillo, Patricia S. Maysent, Chad VanDenBerg, John Bell, and Christopher A. Longhurst, all at UC San Diego Health.
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