Reducing Hospital Readmissions: Effective Discharge Planning Strategies
- Christopher Zambakari
- Jul 7
- 4 min read
Dr. Christopher Zambakari, B.S., MBA, M.I.S., LP.D.
Owner/Operator; Desert Haven Home Care, Apollo Residential Assisted Living, Villa Fiore Assisted Living-Prescott Valley
Under a single home care umbrella, Desert Haven Home Care, Apollo Residential Assisted Living, and Villa Fiore Assisted Living-Prescott feature unparalleled care, feature unparalleled care, service and advocacy in the compassionate treatment of senior citizens in need of medical attention. Offered in a familial setting, the facilities are teamed by professionals passionate about their work and fully engaged in the welfare of residents. Each facility proudly provides patient-centric supervisory, assisted and directed care, short-term respite stays and memory care support for Alzheimer’s and dementia patients.
Just when you thought it was safe to return to the waters of hospital recovery …
A troubling pattern of patient hospital returns within 28 days of release is more common than most would guess, growing in the past four years by almost 25 percent. More troubling: Research reveals that healthcare providers could have prevented up to 27.1% of these readmissions.
Below are some of the causes of hospital readmissions, followed by some tools to help slow the readmission roll.
Common reasons for hospital readmissions
Certainly, medical complications after release lead to hospital readmission, especially when surgery is involved. Other common causes include GI complications and infections at the surgical site. Such issues follow specific patterns. GI issues peak at 40% within five days of discharge and drop to 18% after 12 days. Surgical site infections behave differently, starting at 26% immediately after discharge and rising to 42% once beyond the 12-day mark.
Medication problems create challenges, too. A startling one-half of all adult patients experience medication errors; about 20% deal with adverse drug reactions after leaving the hospital. These issues typically involve heart medications, pain relievers, antibiotics, and diabetes medicines.
Social needs/economic considerations impact readmission patterns. Patients burdened by below-standard housing or other challenges based on low income face greater risk of returning to the hospital than those without such hardships.
Hospital-acquired infections remain a serious issue. Pneumonia, urinary tract infections, and septic shock often lead to preventable readmissions. These complications, along with ongoing symptoms, cause 72% of readmission cases.
Release timing impacts patient recovery. Early discharge ranks among the top reasons for preventable readmissions, and post-discharge care coordination plays an important role in a successful post-hospital transition. Lack of patient follow-up, limited resources, weak administrative support, and low staff involvement make transitional care services less effective.
Release timing impacts patient recovery. Early discharge ranks among the top reasons for preventable readmissions, and post-discharge care coordination plays an important role in a successful post-hospital transition.
High-risk patient groups
The idea, of course, is not to keep all patients from hospital readmission, but to stop the unnecessary ones.
Septicemia, heart failure, and complications from diabetes are among the leading causes of hospital readmissions. Chronic conditions—cirrhosis, hepatic failure, kidney disease—lead to high readmission rates. Elderly patients face unique challenges. The readmission rate hits 36.8% for those aged 90 and older. Frail patients return at a rate of 36.9%, while those with probable dementia have a 39% chance of readmission.
Insurance impacts assurance: Patients without insurance face higher risks because they can’t easily access outpatient care. Tele-health affects patient health: Low-income patients earning below $30,000 yearly struggle with telehealth services—56% don’t have broadband internet.
Mental health issues are a leading reason for hospital re-entry, and patients who leave against medical advice are 1.8 times more likely to return.
Key prevention strategies
Here’s where the rubber meets the road. Prevention.
A thoughtfully planned discharge strategy is the life-blood of preventing hospital readmissions. Personalized discharge plans can drive shorter hospital stays, and the shorter the stay, the less chance of return.
A detailed discharge strategy should include medication checks, patient education, and coordinated follow-up care.
Managing medications properly reduces the risk of readmission. In fact, when pharmacists lead medication reviews and combine them with patient education and transitional care, readmission rates drop by 18%. Medication checks with multiple patient contacts are twice as effective at keeping patients from returning to the hospital.
The timing of follow-up care after discharge is vital. Patients who see their doctors within a week of leaving the hospital show substantially lower readmission rates. Such early follow-up reduces the chance of readmission by 43% when compared to patients without scheduled visits.
The Transition Care Coordinator (TCC) model—hospital care team members repeatedly following up with discharged patients—shows impressive results. TCCs review medications thoroughly, provide clear instructions, and make structured follow-up calls to check symptoms and confirm appointments. With such regular monitoring, fewer surprises crop up that could lead to readmission.
A final note on med checks: Home health services work well as another strategy to ensure effective medication management. These multi-level services are offered to help reduce the chance of hospital readmission. Home health teams provide:
medication education and adherence support.
regular health status monitoring.
coordination between healthcare providers.
early intervention for emerging complications.
In today’s age of evolving technology, automated outreach systems allow for better post-discharge follow-up. Such a system connects with all patients, allowing multiple check-ins during the critical 30-day period.
Electronic health records can make provider communication smoother. This technology makes shared care plans easier and gives primary care doctors full documentation of tests, procedures, and medication changes during hospital stays.
Conclusion
Hospital readmission does not have to be an automatic or guaranteed factor in a patient’s post-release recovery process. Even as we consider the aforementioned high-risk causes for a repeat hospital stay, there are proven tools to help minimize and mitigate the chances of a readmission that may have been preventable.
Readmission prevention works best as an ongoing process rather than a single intervention. Healthcare teams build a strong support system that helps patients recover at home. This happens through detailed discharge planning, medication checks, and steady follow-up care.
About the Author
Dr. Christopher Zambakari is the owner and operator of three Arizona-based assisted living care homes – Desert Haven Home Care in Phoenix, Apollo Residential Assisted Living in Glendale, and Villa Fiore Assisted Living in Prescott Valley, Arizona. He provides direction and oversight to a team of licensed medical and caregiving professionals to ensure the highest levels of customized care, service and advocacy at each of his facilities. Zambakari is founder and CEO of The Zambakari Advisory, an international consultancy in the areas of strategic intelligence, program design and transitional processes. He is a Hartley B. and Ruth B. Barker Endowed Rotary Peace Fellow, and the assistant editor of the Bulletin of The Sudans Studies Association.
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