A Reengineered Hospital Discharge Program to Decrease Rehospitalization

TLDR

Emergency department visits and rehospitalization are common after hospital discharge, and this study tests an intervention designed to reduce such utilization. In a randomized block trial of 749 adults at an urban academic safety‑net hospital, a nurse discharge advocate and a follow‑up pharmacist coordinated post‑discharge care—including appointment scheduling, medication reconciliation, education, and phone reinforcement—to assess 30‑day ED visits and hospitalizations. The intervention reduced 30‑day hospital utilization, with a 30% lower visit rate (0.314 vs 0.451 per person‑month, IRR 0.695, P = 0.009), especially among patients with prior utilization, though adverse events were not evaluated.

Abstract

Emergency department visits and rehospitalization are common after hospital discharge.To test the effects of an intervention designed to minimize hospital utilization after discharge.Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.General medical service at an urban, academic, safety-net hospital.749 English-speaking hospitalized adults (mean age, 49.9 years).A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.A package of discharge services reduced hospital utilization within 30 days of discharge.Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.