Impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review

This review (11 studies) found 22 of 29 outcome results showed a reduction in hospital readmission rates associated with transitional care interventions; the most impact was seen with high intensity interventions lasting at least one month and targeting those at highest risk.

SPS commentary:

All studies included pre-discharge components (e.g. discharge planning, patient education, medicines reconciliation, nutritional screening, physical exercise) and post-discharge components (home visits, telephone follow-up, referral to additional healthcare services, nurse availability or rapid and intensive community support). On an individual level, 7 of the 11 studies showed an entirely positive impact on readmissions, three showed no impact, and one presented both a positive and negative impact.

BMJ Open