Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending~Primary Aim:~To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH~Secondary Aim:~To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH