Discharge from hospital is a key moment in the care of patients over 75 years of age. The organisation of the transition from hospital to home by home help and care management networks can be effective. Our aim was to evaluate impact of a case management program on 30 days rehospitalisation rates. Retrospective study of the multicentre cohort type carried out on patients monitored by the MAIA of Aube between 2018 and 2020. The risk of re-hospitalisation was significantly lower at 30 days among MAIA patients (1.6% vs. 19.5%; p < 0.0001), as well as at 90 days (4.8 % vs. 35.8 %; p < 0.0001). On the other hand, lengths of stay were longer in this group (20.9 vs. 11 days; p = 0.005) and the patients consulted the emergency department more often (40.8 % vs. 17.1 %; p < 0.0001). We could not conclude on mortality and falls. A positive impact of the Aube MAIA scheme on early and late readmission to hospital was shown.
Keywords: 30 days readmissions; Elderly people; case magement; prevention.