Discharge transition programme to reduce readmission to hospital among older people: a feasibility study.

Purpose: Supporting discharge from hospital may reduce readmission among older people. This was a feasibility study of a discharge transition programme which utilised a combination of a discharge transition coordinator, a self-reporting questionnaire of health and care needs, and a telecommunication messaging service.

Methods: Older people admitted to an acute geriatric medicine ward of a university hospital were eligible to participate. Those recruited completed an online questionnaire of their health status twice a week for 2 weeks. They could highlight queries in-between questionnaires via text messages up to 28-days post-discharge. The coordinator would facilitate any health queries between the participant and the medical team. Data were collected on their demographics, clinical details, questionnaire completion, and outcomes at day 28.

Results: One hundred thirty participants (130) were recruited. 71.8% of those eligible were recruited. 69/130 (53.1%) participants were women and their mean age was 81.9 years. They were frail (Clinical Frailty Scale ≥ 4, 90.8%), multimorbid ≥ 3, 72.3%) and had multiple acute medical diagnoses on admission (≥ 2 diagnoses, 89.2%). One hundred four participants (80.0%) returned home with family support. One hundred and seven, 107 (82.3%), completed at least one questionnaire. Fifty-one (39.2%) reported their health status all four times. On average, ten additional queries arose weekly via the messaging service. Concerns included changes in consciousness, reduced oral intake, mobility limitations, and medication uncertainties. 26/130 (20.0%) were readmitted and 9 (6.9%) died within 28 days of their discharge. Most expressed a positive satisfactory response with the programme.

Conclusion: This study provided insight into what is required before performing an adequately powered clinical trial to evaluate its impact on reducing readmission among older people.