A Standardized Discharge Process to Reduce Unplanned Hospital Readmissions

1Baystate Medical Center, Springfield, MA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 208


Hospital readmissions, a consequence of fragmentation of care, has recently been described as a crisis of health care safety, cost, and patient experience. Reducing unplanned readmissions is especially challenging. Despite the emergence of a variety of best practices, the evidence for interventions that result in meaningful improvement remains scanty.


We used best practices gleaned from the Commonwealth Fund/Institute for Healthcare Improvement's STAAR (State Action on Avoidable Rehospitalizations) Initiative and Project BOOST as a basis to develop and implement a multidisciplinary standardized discharge process to reduce unplanned readmissions.

FIGURE 1. All‐cause readmissions to general medical unit.

FIGURE 2. All‐cause readmissions to heart failure unit.


Between October 2009 and March 2010, we convened a multidisciplinary team of hospitalists, nurses, and case mangers to develop consensus on a standardized discharge process and to train staff on 2 pilot nursing units dedicated to general medicine and heart failure (HF) care. The standardized process includes: an assessment on admission of each patient's readmission risk and post‐discharge home needs; a structured discharge preparation and patient and family education using the “Teach‐Back” and “Ask Me 3” tools; a body weight scale for HF patients; a postdischarge appointment at the time of discharge; a postdischarge telephone call from a nurse based on the discharge unit to assess the patient's clinical status, medication, and appointment issues and understanding of the key elements of the hospitalization and to address questions; and for high‐risk and HF patients, a home visit with a visiting nurse the day after discharge. As shown in Figures 1 and 2, in the 4 months following the onset of the program, the 30‐day all‐cause readmission rate decreased by 36% on the general medical unit (Fig. 1). On the medical unit dedicated to medical and heart failure patients, the readmission rate decreased by 41% (Fig. 2). Readmission rates were not seen to decrease significantly on other general medicine or cardiac units.


A standardized, multidisciplinary discharge process using risk assessment, structured education, established postdischarge appointments, a scale for HF patients, a postdischarge telephone call by a nurse from the discharge unit, and a post‐discharge nurse visit at home can substantially reduce unplanned hospital readmissions.


W. Whitcomb ‐ Society of Hospital Medicine, employment; R. Sittig ‐ none; D. Rose ‐ none; J. Fitzgerald ‐ none

To cite this abstract:

Sittig R, Rose D, Fitzgerald J, Whitcomb W. A Standardized Discharge Process to Reduce Unplanned Hospital Readmissions. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 208. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-standardized-discharge-process-to-reduce-unplanned-hospital-readmissions/. Accessed March 31, 2020.

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