Research Highlights Effective Strategies To Prevent Hospital Readmissions

Telehealth and Care Coordination Reduce Readmissions Telehealth programs along with caregiver, social needs, and behavioral health support may reduce hospital readmissions for high-risk patients, according to an AHRQ-funded study in the Journal of Patient Safety. The study assessed a connected transitional care program for high-risk patients. Among 1,374 patients who participated, 32 percent received a followup telehealth visit after discharge. Their readmission rate was 18.7 percent, compared with 21.3 percent for nonparticipants. Chart reviews also linked lower readmission rates to earlier followup after discharge, greater family or caregiver involvement, fewer language barriers, and less altered mental status. The authors called for more rigorous studies to understand how telehealth can best help all patients avoid readmission. Read the full article. https://pmc.ncbi.nlm.nih.gov/articles/PMC12453088/ Centralized Discharge Care Lowers Readmissions Systemwide Implementing a hospitalwide Discharge Care Center (DCC) at Vanderbilt University Hospital reduced 30-day readmissions by 6.6 percent over 2 years, a new study in NEJM Catalyst found. The DCC model provides personalized, risk-based postdischarge support through automated text messages or calls, a DCC hotline, nurse triage, and multidisciplinary care coordination. The approach reached 80,247 patient discharges, of which 23,050 received targeted interventions addressing postdischarge care needs such as new or worsening symptoms, patient education, and medication-related questions. The authors share practical guidance for hospitals interested in replicating the model, emphasizing the importance of automation, real-time data review, and regular feedback loops with leadership. The approach demonstrates how a scalable, systemwide strategy can meaningfully reduce readmissions, improve patient outcomes, and save costs across diverse hospital settings. https://pubmed.ncbi.nlm.nih.gov/41255830/