Reducing readmission rates through a discharge follow-up service

Area of Science:

• Geriatric Medicine
• Healthcare Management
• Nursing Practice

Background:

• Approximately 15% of elderly patients face hospital readmission within 28 days.
• High readmission rates incur significant costs for the National Health Service (NHS) and patients.
• Prior research suggests post-discharge telephone contact can decrease readmission rates.

Purpose of the Study:

• To evaluate the impact of community nurse follow-up on 30-day emergency readmission rates in elderly patients.
• To compare readmission rates between patients receiving a community nurse follow-up attempt and a control group.

Main Methods:

• A cohort study design was employed, analyzing data from 756 elderly patients across seven hospital wards.
• Patients were divided into an intervention group (n=303) receiving community nurse follow-up and a comparison group (n=453) with no contact attempt.
• Hospital admission and readmission data were collected over a six-month period.

Main Results:

• The readmission rate was 9.24% in the group where contact was attempted, versus 15.67% in the group with no contact attempt (p=0.011).
• Logistic regression analysis, adjusted for confounders, indicated a significant reduction in readmissions for the 'attempt to contact' group (OR=1.93, 95% CI=1.06-3.52, p=0.033).
• Of those contacted, 202 patients received a home visit, with general practitioner referrals and medication advice being common interventions.

Conclusions:

• A simple intervention involving community nurses attempting to contact and visit geriatric patients post-discharge significantly reduces 30-day hospital readmissions.
• This proactive approach offers a cost-effective strategy for improving patient outcomes and reducing healthcare burdens.
• Community nurse follow-up is a valuable tool in managing elderly patient care transitions and preventing unnecessary hospitalizations.