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Post discharge phone calls and home visits linked to near halving of readmissions

Simple aftercare measures associated with 41% drop in elderly patients needing to go back to hospital within 30 days

Caroline White

Friday, 14 June 2019

Hospital readmissions for elderly patients could be almost halved, using relatively simple aftercare measures, such as post-discharge phone calls and home visits, suggests research* published in Future Healthcare Journal.

A community nurse, offering straightforward telephone advice on medicines management, through to referrals to community health providers, including GPs and pharmacists, were associated with a 41% fall in the number of readmissions patients within 30 days among older patients, the findings showed.

The research looked at two groups of elderly patients in Solihull, West Midlands: 303 whom community nurses attempted to contact to offer a home visit after discharge, and a comparison group of 453 who were not contacted. Successful telephone contact was made with 288 of the 303 patients, 202 of whom received a home visit.

Almost 16% of the comparison group were readmitted as emergencies within 30 days of leaving hospital. But among those whom community nurses contacted and visited, that figure was only 9%. This indicates that patients who weren’t contacted were almost twice as likely to be readmitted to hospital within 30 days of discharge.

Co-author, Dr James Brown, senior lecturer in life and health sciences at Aston University, said: “Our work shows that a simple service, whereby community nurses attempt to contact older adult patients after they are discharged from hospital, led to a significant reduction in the number of patients readmitted within a month.

“It may seem hard to believe that something as simple as a phone call can have such a major impact, but our evidence suggests that this is so – the NHS could tackle the rise in readmissions by implementing simple, inexpensive telephone services which improve communication with patients.”

He added: “The combination of Britain’s ageing population and an under-pressure NHS means it is now more important than ever to minimise the costs to our health services caused by unnecessary readmissions.”

Figures from NHS Digital published in March this year showed that there were 865,625 emergency readmissions to hospital within 30 days of discharge in England in 2017-18. Around 15% of over-65s are readmitted within 28 days.

Based on its analysis of data from 70 hospital trusts in England, patient watchdog Healthwatch found that between 2013-14 and 2017-18 emergency readmissions increased by nearly 22%. Healthwatch estimated that emergency readmissions cost the NHS around £2.4bn every year.

Dr Brown added: “While NICE guidance recommends that a discharge coordinator should follow-up with people leaving hospital within 24 hours, the rising rates of readmissions, especially for older people, suggest this isn’t happening as a matter of course.

“This new evidence suggests NHS trusts and community teams could substantially reduce the pressure on their services from simple interventions, potentially freeing up thousands of beds and cutting the huge costs associated with unplanned hospital stays.”


* Vernon D, et al. Reducing readmission rates through a discharge follow-up service. Future Hosp J June 1, 2019 vol. 6 no. 2 114-117. DOI: 10.7861/futurehosp.6-2-114

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