Reducing Readmissions: Nurse-Driven Interventions in the Transition of Care From the Hospital

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Transitions of care (TOC) from hospitals is a continuing focus for quality improvement to reduce readmissions. Sufficient resources to offer interventions remain an issue for hospitals, leading to efforts to target high-risk patients and identify effective interventions.


Describe and measure effects, hospital-wide and among high-risk patients, of a multifaceted TOC program on 30-day readmissions in a 441-bed acute care community hospital.


Pre-post TOC intervention examining 30-day readmission rates during planning, implementation, and intervention years compared to baseline. Patient characteristics and services received by patients targeted for TOC individualized interventions during hospitalization and after discharge were retrieved from medical records and compared over 4 years during which the intervention was planned and implemented.


Summary hospital-wide readmission rates reduced from 11.8% during planning (2011), 12.0% during implementation (2012), to 11.4% during intervention (2013) compared to 13.7% at prestudy baseline (2010; p < .001). TOC program patients were mostly identified by clinician referral (66.7%) rather than computer-generated risk at admission (32.3%), and nearly one-third (30.6%) were readmitted within 30 days of release.

Linking Evidence to Action

Reductions in readmissions were achieved using a multifaceted approach with efforts at admission, predischarge, and postdischarge in a community hospital. Having clinical staff involved in TOC program is important in both patient identification and interventions to reduce readmissions.

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