Structured, Nurse-Led Post-Discharge Follow-Up Calls to Reduce 30-Day Hospital Readmissions: A Quality Improvement...

Area of Science:

• Healthcare Management
• Nursing Practice
• Patient Safety

Background:

• Hospital readmissions present a significant challenge to patient safety and healthcare system efficiency.
• Ineffective discharge education and care transitions contribute to patient vulnerability post-hospitalization.
• Structured follow-up calls within 24-72 hours show promise in reducing readmissions and improving transitions.

Purpose of the Study:

• To assess the efficacy of nurse-led telephone follow-up calls, using the AHRQ RED Toolkit, in decreasing 30-day hospital readmissions.
• To evaluate the impact of a structured post-discharge intervention on patient outcomes and care continuity.

Main Methods:

• A quality improvement initiative was conducted over 12 weeks at a 200-bed urban medical center.
• Registered nurses performed standardized follow-up calls within 24-72 hours of discharge, addressing key health aspects.
• Readmission data were collected pre- and post-intervention from electronic health records for analysis.

Main Results:

• The readmission rate decreased from 17% in the standard care group (n=287) to 3.5% in the intervention group (n=112).
• This represents a significant absolute reduction of 13% in 30-day hospital readmissions (p=0.0005).
• Patients reported enhanced satisfaction and confidence in managing their health post-discharge.

Conclusions:

• Integrating structured, nurse-led post-discharge follow-up calls into standard workflows is recommended to minimize preventable readmissions.
• This low-cost, scalable intervention strengthens transitional care, improves patient safety, and supports value-based care.
• Findings support the broad implementation of nurse-led follow-up calls as a cost-effective, evidence-based strategy.