ABSTRACT
BACKGROUND: Medical patients with a recent previous hospitalisation are at very high risk of subsequent readmission. Evidence suggests that improving key transition processes may reduce hospital readmissions. This study describes quality of transition processes in frequently admitted medical patients, to inform system improvements for this high risk group. METHODS: Retrospective records review of consecutive medical inpatients aged 50 years or older in a major metropolitan teaching hospital in Australia with a recent (within 6 months) prior hospitalisation. Information was sought on 4 key processes: discharge summary completed and sent within 2 weeks; discharge medication reconciliation; patient/carer discharge education; and timely scheduling of outpatient review with the treating team. Readmission rates were obtained from a state-wide admissions database. RESULTS: Discharge processes for 209 live discharges in 164 patients were reviewed. Although timely discharge summary completion (81%) and discharge medication reconciliation by a pharmacist (81%) were high, there were major gaps in patient education (33%) and in timely outpatient review (12%). Outpatient systems appear poorly organised to support high quality transitions. Readmission rates were high (23% at 30 days and 58% at 180 days). Individual discharge quality processes did not predict readmissions. DISCUSSION: Gaps in transitional care of frequently attending medical patients provide potential targets for improvement. In particular, opportunities for better patient/carer education and timely, structured outpatient review may inform design of improved transitions for this high risk group, to be tested in prospective controlled trials.
