Reducing readmission rates through a discharge follow-up service

Approximately 15% of elderly patients are readmitted within 28 days of discharge. This costs the NHS and patients. Previous studies show telephone contact with patients ­post-discharge can reduce readmission rates. This service ­evaluation used a cohort design and compared 30-day emergency readmission rate in patients identified to receive a community nurse follow-up with patients where no attempt was made. 756 patients across seven hospital wards were ­identified; 303 were identified for the intervention and 453 in a ­comparison group. Hospital admission and readmission data was extracted over 6 months. Where an attempt to contact a patient was made post-discharge, the readmission rate was 9.24% compared to 15.67% where no attempt to ­contact was made (p=0.011). After adjustment for ­confounding using logistic regression, there was evidence of reduced readmissions in the ‘attempt to contact’ group odds ratio = 1.93 (95% c­onfidence interval = 1.06–3.52, p=0.033). Of the patients who community nurses attempted to contact, 288 were contacted, and 202 received a home visit with general practitioner ­referral and medications advice being the most common ­interventions initiated. This service evaluation shows that a simple intervention where community nurses attempt to contact and visit geriatric patients after discharge causes a significant reduction in 30-day hospital readmissions.