Analysis of Hospital Readmission among PACE Participants in Oregon
Files
Publication Date
4-29-2026
Keywords
oregon, pmg pharmacy, pmg pharmacy gme
Disciplines
Medical Education
Abstract
Introduction: Older adults face an elevated risk of hospitalization-associated harms, including falls, cognitive decline, and functional loss. Unplanned readmissions affect 15%–30% of Medicare beneficiaries annually and contribute an estimated $12 billion in potentially preventable costs. For programs of All-Inclusive Care for the Elderly (PACE), understanding factors that contribute to repeat or medication-related hospitalizations is critical for improving patient care, and informing pharmacist-led interventions aimed at reducing avoidable admissions. Objective: This project seeks to identify trends and potentially preventable causes of hospital readmissions among PACE participants and to evaluate opportunities for targeted interventions. Methods: A retrospective chart review was conducted using data from EPIC and PACE internal systems. The study included Oregon PACE participants with more than one hospitalization between January 1 and December 31, 2024. Hospitalizations occurring before PACE enrollment and elective admissions were excluded. Results: A total of 583 admissions involving patients more than one hospitalization were initially identified. After applying exclusion criteria, 449 admissions among 160 patients were included. The mean age was 74 years, 107 (66.9%) were female, 63 (39.4%) resided in adult family homes, and 16 (10.0%) were receiving palliative care. Urinary tract infection was the most common discharge diagnosis (75 admissions, 16.7%), followed by heart failure (61 admissions, 13.6%). Medication-related causes accounted for 56 admissions (12.5%), most frequently involving central nervous system agents (16 admissions, 28.6%) and opioids (10 admissions, 17.9%). Admissions were evenly distributed by month with an average of 37 admissions per month; July had the highest number (45). Among the 449 admissions, 29 (6.5%) involved a fall prior to admission, 113 (25.2%) were 30-day readmissions, and 326 (72.6%) had at least one PACE encounter within 3 days prior to admission. The estimated total cost of hospitalization for these admissions was $7,237,500. Conclusion: Pharmacist-led interventions targeting urinary tract infection prevention, central nerve system medication optimization, and close follow-up may reduce preventable readmissions in PACE participants.
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Pharmacy
