Evidence Brief No. 24 - Avoiding hospital readmissions: the models and the role of primary care

Avoiding unplanned readmission is important. Unplanned hospital readmissions indicate suboptimal patient outcomes, care coordination and quality of care and contributes to significant avoidable healthcare costs. A significant proportion of hospital readmissions are avoidable and vulnerable groups, such as older people, are disproportionally affected by unplanned readmissions. The transition between hospital to the community requires good multi-disciplinary cooperation and timely, comprehensive, and accurate communication. However, these are not always achieved.

This paper discusses different models of care reported in the literature which have been used to prevent unplanned hospital readmissions, including those models that improve transitional care, as well as virtual wards and telehealth. This brief also discusses the potential role of primary care, specifically general practice, in helping to reduce hospital readmissions.