How can team readmission be reduced in patients after discharge?

Reducing Team Readmissions After Hospital Discharge

Implement a multidisciplinary disease management program with early follow-up within 7 days of discharge, combined with patient-centered discharge instructions and a clear transitional care plan—this approach reduces readmissions by up to 44% and mortality by 81%. 1

Core Strategy: Multidisciplinary Team-Based Care

Refer high-risk patients to multidisciplinary disease management programs (Class I recommendation, Level B-R evidence), as this is the most effective intervention for reducing hospitalizations and improving outcomes. 1 These programs should include:

• Cardiologists and hospitalists for medical management 2
• Advanced practice providers (nurse practitioners/physician assistants) for care coordination 1
• Clinical pharmacists for medication reconciliation and optimization 2
• Specialty nurses for patient education and follow-up 2
• Social workers for addressing psychosocial barriers 1
• Dieticians for nutritional counseling 1
• Case managers to coordinate care transitions 1

This multidisciplinary approach reduces all-cause readmissions by 56% and heart failure-specific readmissions by 56.2% compared to conventional care. 3

Critical Timing: Early Follow-Up

Schedule follow-up within 7 days of discharge (Class IIa recommendation, Level B-NR evidence), as this timing is reasonable to optimize care and reduce rehospitalization. 1 Evidence shows:

• Outpatient appointments within 30 days reduce 30-day mortality by 81% (95% CI, 0.09-0.43). 1
• Physician visits within 21 days significantly reduce readmissions. 1
• Nurse-led transitional stroke clinics with follow-up phone calls and office visits at regular intervals effectively reduce readmission rates. 1

Essential Discharge Planning Components

Provide patient-centered discharge instructions with a clear transitional care plan before hospital discharge (Class I recommendation, Level B-NR evidence). 1 The discharge plan must specifically address:

• Precipitating causes of hospitalization and how they will be managed 1
• Diuretic adjustments based on volume status, weight monitoring, and electrolytes 1
• Safety laboratory checks (e.g., electrolytes after medication changes) 1
• Medication reconciliation including plans for resuming held medications, initiating new medications, and titrating to goal doses 1
• Patient and family education on disease management, dietary restrictions, and physical activity 1
• High-risk characteristics: comorbidities (renal dysfunction, diabetes, mental health disorders), psychosocial support limitations, health literacy, and cognitive impairment 1

Poor preparation before discharge, insufficient medication reconciliation, and lack of education on anticipated needs are key patient-reported factors leading to readmission. 1

Intensity of Intervention Matters

High-intensity transitional care interventions combining home visits with telephone follow-up reduce readmissions regardless of follow-up duration. 1 Specifically:

• High-intensity programs (home visits + telephone + clinic visits) reduce all-cause readmission and the composite endpoint of readmission or death at 30 days and 3-6 months (moderate strength of evidence). 1
• Moderate-intensity interventions are efficacious only if implemented for at least 6 months. 1
• Low-intensity interventions (outpatient clinic or telephone follow-up alone) are NOT efficacious. 1

Proven Outcomes from Multidisciplinary Interventions

Evidence demonstrates substantial benefits:

• 41.5% reduction in length of stay for delayed discharge patients without increasing readmissions 4
• Readmissions decreased from 18% to 12% (p<0.001) with health team communication redesign 5
• 90-day readmission rates reduced from 69.8% to 27.3% (p<0.001) with multidisciplinary programs 1
• Hospital nights reduced by 60% (1,228 vs 492 nights, p=0.009) in intervention groups 6
• Overall cost savings of $460 per patient despite intensive interventions 3

Performance Monitoring

Participate in systems allowing benchmarking to performance measures (Class IIa recommendation, Level B-NR evidence) to increase use of evidence-based therapy and improve quality of care. 1 This systematic approach promotes:

• Improved communication between healthcare professionals 1
• Systematic use and monitoring of guideline-directed medical therapy 1
• Consistent documentation across care transitions 1

Common Pitfalls to Avoid

• Do not rely on telehealth self-monitoring alone—it is not effective in reducing readmissions or improving quality of life for underserved patients. 1
• Do not delay follow-up beyond 7 days—patients are at highest risk for decompensation in the days and weeks immediately post-discharge. 1
• Do not implement low-intensity interventions—they have been proven ineffective. 1
• Do not neglect medication reconciliation—this is a frequently cited patient-reported factor leading to preventable readmissions. 1

Special Populations at Higher Risk

Identify and provide enhanced interventions for:

• Patients with comorbid diabetes, metabolic or mood disorders, and renal impairment have significantly higher readmission rates 1
• Patients with recurrent hospitalizations particularly benefit from multidisciplinary programs 1
• Elderly patients (≥65 years) paradoxically have less follow-up despite higher comorbidities 1