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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.