A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.
Adverse events after hospital discharge are disturbingly common, occurring in up to 1 in 5 hospitalized patients. Flawed hospital discharge processes—which include lack of medication reconciliation, poor communication with primary care physicians, and failure to provide patient education—likely contribute to adverse events and hospital readmissions. In this study, a discharge advocate (a trained nurse) met with patients prior to discharge and created a patient-centered discharge plan, which was given to the patient and primary physician. Patients also received a follow-up phone call from a pharmacist after discharge. The intervention successfully reduced hospital utilization in the 30 days after discharge, primarily by reducing emergency department visits. A similar but more resource-intensive intervention, the care transitions trial, also was successful in reducing 30- and 90-day readmission rates.