Discharge planning, Follow-up phone calls, Hospital discharge, Hospital readmission, Patient discharge, Patient education, Patient readmission



  1. Kamermayer, Angela K. DNP, APRN-CNS, NEA-BC
  2. Leasure, A. Renee PhD, APRN-CNS, CCRN
  3. Anderson, Lisa BA


Background: The Affordable Care Act of 2010 set forth payment models that provided $10 billion to incent the health care system in developing innovative programs that target reform, including transitional care to reduce preventable readmissions. While transitional care programs exist, US hospitals remain challenged, with 1 in 5 readmissions within 30 days.


Objective: This systematic review examined the effectiveness of select evidence-based transitions-of-care interventions on reducing 30-day readmission rates, reducing emergency room visits, and reducing mortality rates.


Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines formed the framework for this systematic review. Key study characteristics informed the eligibility criteria and search strategy. Two reviewers independently appraised selected studies using the Critical Appraisal Skills Programme tools. Included studies were summarized and synthesized in order to draw conclusions across studies.


Results: Interventions are aimed at reducing the readmission rate of the adult general medical population. The population of focus in this review includes patients at risk of avoidable readmissions, which includes patients requiring higher levels of care secondary to complications that can contribute to higher mortality after discharge from an acute care setting.


Discussion: The findings of this review support the use of transitions-of-care interventions such as tailored discharge planning and postdischarge phone calls.


Article Content

Transitions of care (TOCs) represent a phase of health care that connects the patient between health care settings.1 The discharge planning process influences the effectiveness of TOCs in addressing patient safety and quality outcomes after inpatient admission in acute care hospitals. Unplanned 30-day readmissions may link with gaps in TOCs because of lack of integrated discharge planning, post-acute care, and self-management ability. Many TOC programs target reducing readmissions with standard discharge instructions, postdischarge appointment scheduling, and postdischarge follow-up phone calls. Interventions aimed to reduce hospital readmissions may benefit from discharge planning that addresses TOCs. Transitions-of-care interventions target reducing the risk of preventable complications in order to reduce readmission to an acute care facility, reduce mortality, and reduce unplanned costs of care.


The objective of this systematic review was to examine the evidence supporting the effectiveness of TOC interventions integrated with discharge planning as compared with usual discharge process in reducing 30-day hospital readmissions. The review subobjectives included examining the effectiveness of enhanced discharge planning on the outcomes of postdischarge follow-up with outpatient primary care provider and medication adherence.


The significance of this systematic review may support that evidence-based TOC interventions reduce preventable readmissions. In addition, evidence-based protocols can enhance the discharge planning process and support patient family engagement that reduce the risk of readmission.



Reviewers conducted a systematic review focused on TOCs among general medical-surgical inpatients, which was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Paired reviewers worked independently to establish MeSH and key word search terms based on a PICO (problem, intervention, comparison, outcome) question to compare the difference between TOC interventions and routine discharge planning to reduce the 30-day readmission rate among general medical patients discharged from acute care hospitals.


Eligibility Criteria

Study eligibility included published research articles with both single and multiple interventions aimed at reducing hospital readmissions. Representative articles included hospital-initiated interventions for postdischarge provider appointments and follow-up phone calls. Reviewers selected English-language records from any country. The review was limited to studies of adults who had a discharge destination of home, skilled nursing, or long-term acute care. The review excluded studies in the following groups: (1) pediatrics, (2) obstetrics, (3) psychiatric conditions, or (4) disease-specific populations. The full-text article was reviewed in situations where we were unable to determine inclusion and exclusion criteria. Study outcomes of interest included 30-day readmission, mortality, and emergency room (ER) visits within 30 days after discharge.


Information Sources and Search

Electronic databases provided access to studies that identified candidate records by search terms selected by the reviewers. Reference lists assisted reviewers in finding additional hand-searched relevant records dated 1945 to week 5 of August 2016. The reviewers collaborated with a research librarian using MeSH search terms in MEDLINE. The following MeSH subject headings, search terms, and Boolean operators guided the search for records: patient discharge, patient readmission, patient discharge AND patient readmission, hospital discharge, hospital readmission, hospital discharge AND hospital readmission, patient readmission AND patient education OR discharge planning OR follow-up phone calls. Other databases used the same search including CINAHL, Cochrane Library for Register Controlled Trials (August 2016), and the Web of Science. EMBASE used similar terms that mapped to the EMTREE subject headings. After excluding duplicates, editorials, and commentaries, the reviewers used reference lists to identify additional records. Missing data included a plan to contact authors if deemed needed to establish relevancy.


Study Selection

Reviewers screened studies using titles and abstracts that resulted from search terms. Studies selected for full-text review supported relevance to the systematic review (see Figure). The following criteria included (1) interventions to reduce readmission to an acute care hospital setting and (2) discharge planning interventions. All studies screened used eligibility criteria first by title, then by abstract review. Reviewers pulled all studies meeting inclusion criteria for full-text review. Full-text review also included related studies uncertain for inclusion. Although review studies did not meet the inclusion criteria, they served as a basis to identify additional studies that described interventions used to reduce readmissions to acute care hospitals. Reviewers resolved conflicts in study selection through critical appraisal methods. The final selection of studies included 13 from the systematic review and new articles that were identified in reference lists of selected studies (see Supplemental Digital Content 1,

Figure. Preferred Re... - Click to enlarge in new windowFigure. Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram of search and study selection process.

Data Abstraction and Quality Assessment

Reviewers first reviewed and extracted data independently. Qualitative appraisal was conducted using the Critical Appraisal Skills Programme (CASP) tools, This suite of critical appraisal tools has tools specific to different study designs. The randomized controlled trial appraisal tool was used to appraise randomized controlled trials, the cohort appraisal tool was used for cohort studies, and so on. The CASP tools provide a framework for systematically evaluating study quality by addressing threats to design validity, which may vary across different study designs. A second review followed the initial data review to compare appraisals for consistency. The reviewers discussed clarity of the data by finding evidence in the articles to support the effect of the interventions. A third review between reviewers achieved final consensus.


Data Items

Studies selected included the population characteristics of interest to reduce the readmission rate. Two randomized controlled trials selected represented 1450 general medical inpatients.2,3 Both trials studied hospital-initiated interventions and outcome measures with some overlap. Overlapping interventions related to discharge education. A common outcome measured across studies included 90-day readmission rates. Researchers measured patient risk factors for hospital readmission to determine whether referral to a primary care provider occurred prior to hospital discharge. The remaining selected articles included cohort studies and represented multiple interventions across studies with varied overlap in primary care provider appointment, discharge education, and follow-up phone calls. No 2 studies compared alike and with TOC interventions implemented by a variety of roles including nursing, case management, social services, and providers. Outcome measures included 30-, 60-, and 90-day readmissions; 30-day mortality; and emergency department visits.


Risk of Bias

Paired reviewers independently analyzed the studies for validity and reliability of data. Missing data led to discussion between the reviewers prior to further analysis. The reviewers made the final selection of eligible articles based on findings of the critical appraisal process. Reviewers discussed group characteristics and differences that may influence outcomes. For example, participants admitted through the emergency department may differ from participants who present as a direct admit. These differences in entry point may reflect the stability of an acute condition that may impact outcomes. In addition, accessibility of the primary care provider may be affected by differences in geographic distances affecting health care resources and follow-up variation among the groups studied.


Summary Measures

Individual studies measured binary results as differences between usual and intervention groups: (1) mean difference, (2) odds ratio, (3) hazard ratio, and (4) incidence rate ratio. The primary measure for readmission served as the mean difference for intervention effect. Odds ratios measured readmission rates when comparing differences between the intervention and usual care groups. Hazard ratios measured the relative risk of outcomes at different points in time from index hospital discharge such as 30-, 60-, and 90-day readmissions; mortality; and ER visits. An incidence rate ratio measured the incidence of the ratios between 2 separate groups, meaning that a group exposed compared with a group unexposed to the intervention. Supplemental Digital Content 2 (see Supplemental Digital Content 2, provides a summary of the outcome measures and significance of the interventions.



This systematic review aimed to assess the clinical effectiveness of TOC interventions to reduce 30-day readmission rates. The initial search included 220,978 records. After title and abstract review, 98 records remained for full-text review. Based on inclusion and exclusion criteria, 13 studies were identified that examined the effectiveness of TOC interventions to reduce the readmission rate for general medical inpatients. Studies excluded pertained to disease, clinical conditions, or specific surgical procedure readmissions. The analysis of records included interventions initiated while the patient was hospitalized with follow-up after discharge.


The review analyzed results of studies by outcomes and then by the interventions. Findings demonstrated that multiple TOC interventions ranged from 1 to 7 per study. All studies included interventions initiated prior to discharge from the hospital. Outcomes revealed variability ranging from a reduction, no effect, and increased risk of readmission and health utilization among general medical inpatients.



Studies included in this review utilized multicomponent discharge interventions including standardized discharge instructions,4,5 a postdischarge provider appointment,6-13 follow-up phone calls5-7,9,11,13 and medication reconciliation.2,4-6 While some studies utilized a dedicated TOC2,3,5-9 employee, others utilized a team-based approach.14,15 While the majority of the studies utilized inpatient-based personnel who worked to transition the patient to the home setting, Coleman et al2 utilized an outpatient approach where a community-based advanced practice nurse visited the patient prior to hospital discharge and then implemented TOC interventions in the home.


The Effectiveness of TOC Interventions in Reducing 30-Day Readmission Rates

Researchers studied postdischarge provider appointment and telephone follow-up interventions to affect the 30-day all-cause readmission rate. Using these interventions, 6 studies demonstrated a statistically significant reduction in the 30-day readmission rate.2,4-8 Four of the studies included randomized controlled trials.4,5,9,13 Follow-up phone call frequency varied from 1 to 3 contacts within 30 days of discharge. These studies included a plan for medication reconciliation and provider follow-up. Researchers prescheduled postdischarge provider visits either prior to discharge or after discharge and within 30 days.


Conversely, the interventions of provider follow-up and postdischarge telephone phone calls demonstrated an inverse relationship resulting in indicated higher readmission rates.13 These findings may have been due to heterogeneity between participants and proportions admitted through the ER and direct admissions. Alternately, access to health care advice may have resulted in patients being directed to the ER for early treatment, which may have in fact deterred hospital readmission. In another study, all-cause readmissions indicated no difference involving provider follow-up; however, for related readmissions, there was a significant difference.16 Still other studies did not demonstrate a significant difference between usual care and patient follow-up based on timing of provider appointment.3,15 Follow-up by the provider included a set of multiple interventions performed in discharge planning. Although not statistically significant, results indicated an inverse relationship of increased readmissions in the intervention group, although not statistically significant. This may reflect inconsistencies in the number of interventions provided, as well as increased participant awareness of signs and symptoms to seek help.9


The Effectiveness of TOC Interventions in Reducing 60- and 90-Day All-Cause Readmissions

Researcher interest beyond the 30-day readmission rate provided insights on how the effect of transitional care interventions extended at further points in time. Readmission rates beyond the 30-day interval postdischarge provide additional data about the effect of postdischarge interventions at different points of time. At 60, 90, and 180 days after discharge, a study reported a statistically significant reduction in readmission rates for the same index hospitalization.2 Yet, a study involving postdischarge follow-up phone calls suggested no effect on provider follow-up.10 Another study that used the Re-Engineered Discharge tool kit demonstrated a 44% reduction in readmission from their baseline assessment, but did not report whether the difference was statistically significant.4


The Effectiveness of TOC Interventions in Reducing 30-Day Mortality

There were 2 studies that addressed mortality outcomes in the general medical inpatient population. One study demonstrated no difference in mortality for interventions.5 In another study, mortality reduced with enhanced discharge process interventions, 3.1% versus 4.4%, although not statistically significant.13


The Effectiveness of TOC Interventions in ER Visit Reduction

Two studies examined whether there was an association between discharge interventions and ER utilization 30 days after discharge. One study showed no difference in ER visits.5 The other study indicated no difference, with a slight increase in utilization that the researchers attributed to patients being more aware of warning signs.3 In addition, a difference in outcome may consider geographic location contributing to those who seek care at different facilities. Goldman and colleagues3 experienced a loss to follow-up in patients who lived a significant difference from the facility. These postdischarge patients may have sought follow-up health care services in a geographic locale that was closer to the location where they were residing or had reduced access to care.


The Effectiveness of TOC Interventions in Reducing Cost of Care

Three studies reported cost-of-care differences with variable results. In 1 study, patients receiving postdischarge interventions experienced a significantly lower cost of hospital care from $2546 to $2058.3 No difference in cost of care was found in another multisite study possibility attributed to lower participation rates that affected the power or effect of usual care and limited added benefit of the interventions.3 In another study with multiple interventions, a 33.9% reduction in health care utilization with lower observed costs was noted in both ER visits and primary care provider visits in the intervention group.5



Across studies, comprehensive discharge planning with multiple interventions was associated with a reduction in the risk of hospital readmission in the general medical-surgical patient population.2,4-6,11 Findings may suggest that multiple interventions implemented with a team-based approach are more likely to reduce the readmission rate than single interventions alone. Care team composition varied and included members from acute care and ambulatory practice settings.


Patients at higher risk of readmission may benefit even more from TOC interventions and experience fewer readmissions.6 High-risk medical readmissions include patients treated for heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, and sepsis.12,17,18 Critical care nurses can influence the discharge planning process that contributes to safe discharge among higher-risk patient groups because patients in higher-risk groups are discharged directly from the intensive care unit to post-acute care or medical transfer to higher levels of care. Even so, all-cause readmissions represent a challenge to be reconciled by the health care team. Valuable insights obtained impart the need for further research and evidence-based quality improvement studies. The data demonstrated limited impact on 30-day mortality.5,13 The patients selected to participate in both studies included those with complex disease processes. Thus, the underlying health issues reflect a stronger predictor of 30-day mortality than the characteristics of the discharge planning process.



Variation in group characteristics may influence the effect of interventions on outcomes that are intended to reduce the readmission rate, mortality, ER visits, and cost of care. These variations may be controlled by reducing the heterogeneity of groups, as well as the number of participants involved. In addition, access and geographic availability and spread of health care resources may affect the context for which TOC interventions are implemented.



Growing evidence suggests that TOC interventions among general medical-surgical inpatients reduce readmission rates, mortality, ER department utilization, and costs. These findings indicate that studies that controlled for confounding factors produced similar results with statistical significance. Standardization of interventions imparts the importance to connect the outcome to the intervention. Team-based approaches demonstrated more effectiveness with multiple interventions versus single interventions alone. As members of the care team, nurses play a vital role in the discharge planning process by proximity to influence outcomes of patients at risk of readmission at all levels of care. Nurse leaders can influence care models that include nurses in the discharge planning approach to support TOCs. The studies in this review utilized bundles of TOC interventions. Thus, we were unable to detect the influence of single interventions on outcomes. Further research may isolate interventions that reduce the readmission rate. In addition, more quality improvement studies to test evidence-based interventions on general medical inpatients at discharge, as well as patient populations at risk of readmission. Even though not all readmissions are preventable, multicomponent discharge interventions and a team-based approach are more likely to reduce readmissions and improve outcomes in recently discharged medical-surgical patients.




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