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Preventing Bounce-Back Hospital Admissions

A standardized discharge intervention lowered the incidence of rehospitalization.

Any clinician who has cared for hospitalized patients understands that discharge is a precarious time — processes can go wrong. When patients leave the hospital without clear understanding of their diagnoses, medication instructions, or need for primary care follow-up, chances are that they will wind up back in the emergency department (ED). Many will be readmitted.

In this randomized controlled trial, investigators at Boston Medical Center compared a standardized discharge intervention with usual care for 749 patients who were admitted to the medical teaching service. The intervention had three main components:

• Nurse discharge advocates who coordinated discharge plans with the hospital team and educated and prepared patients for discharge
  
• After-hospital care plans (also coordinated by the discharge advocate), which contained reasons for hospitalization, discharge medication lists with instructions, contact information for discharge advocates and primary care providers, appointment calendars, and lists of pending tests
  
• Follow-up phone contact by clinical pharmacists at 2 to 4 days after discharge to reinforce discharge plans and to address any medication-related problems
  

At 30 days after discharge, 90 patients in the usual-care group versus 61 in the intervention group had visited an ED; 76 readmissions had occurred in the usual-care group versus 55 in the intervention group. The intervention patients were significantly more likely to know their discharge diagnoses (79% vs. 70%), to be able to identify their primary care providers (95% vs. 89%), and to report that they were prepared adequately for discharge (65% vs. 55%). Estimated total direct cost savings for the intervention was US$149,995 — an average of $412 per person who received it.

Comment: This standardized discharge intervention lowered rehospitalization significantly within 30 days of discharge — by approximately 30% among medical patients. A limitation of the study is that it was conducted at a single urban center. Whether the intervention would have the same effect for a patient population with more resources is unclear. Also, although the randomization scheme is described in detail, no information is provided about participants’ discharge diagnoses. Some disease states, such as congestive heart failure, have more-complicated treatment regimens that can result in a greater likelihood of bounce-back admissions. Nevertheless, the results of this study confirm what those working in hospital medicine already know: It’s high time we reconfigure the discharge process.

— Neil H. Winawer, MD

Published in Journal Watch Hospital Medicine February 2, 2009

Citation(s):

Jack BW et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med 2009 Feb 3; 150:178.

• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• The general idea is great
  E.M. Licari, 29 Mar 2009 10:38 PM EST
  Keep pursuing this. Although it may have some loop holes, I believe that it will help with many, many issues.... [more]

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