What is the clinical evidence from this study?

Study design: RCT. Population: High risk for unplanned rehospitalization (n=1704). Intervention: Hospital@Home tailored transition program vs. Usual care. Primary outcome: Rate of first unplanned rehospitalizations within 30 days after discharge.

What question did this study set out to answer?

The trial evaluates the efficacy of a tailored discharge program for patients at high risk of rehospitalization.

March 22, 2026Open Access

Hospital@Home: improving discharge management and reducing the risk of rehospitalizations in multimorbid Patients – Protocol for a randomized clinical trial

Resultado clave

A tailored transition program including bridging and post-discharge interventions will be evaluated for its efficacy in reducing 30-day unplanned rehospitalizations in high-risk multimorbid patients.

Puntos clave

The trial evaluates the efficacy of a tailored discharge program for patients at high risk of rehospitalization.
Pragmatic randomized open-label single-center superiority trial
Participants include adults in an acute internal medicine department at high risk of rehospitalization
Intervention group receives individualized discharge management from an interdisciplinary team
Comparison group receives usual discharge care
Follow-up for 30 days post-discharge
Aims to reduce the 30-day rehospitalization rate in high-risk patients
Expects improved patient outcomes through coordinated discharge interventions

Diseño del estudio

Tipo

RCT (n=1,704)

Enmascaramiento

Open-label

Aleatorización

Stratified by cancer and heart failure

Multicéntrico

PICO estructurado

Does a multimodal discharge intervention reduce the 30-day unplanned rehospitalization rate in high-risk adult internal medicine patients?

Población

Adult patients hospitalized in an acute internal medicine department who are planned to be discharged home with a high estimated risk (≥20%, BARRS-Score ≥5) of 30-day rehospitalization.

Intervención

Multimodal individualized discharge management by an interdisciplinary team (pre-discharge, bridging, and post-discharge interventions including 5-day daily phone follow-up).

Comparador

Usual care (standard-of-care counselling before hospital discharge).

Resultado

Rate of first unplanned rehospitalizations within 30 days after discharge from the index admission.hard clinical

Limitaciones

Due to the open-label intervention, potential contamination and other factors may reduce the differences between the intervention group compared to usual care.
The generalizability of this study may be limited due to the single-center study design.

Resumen

Hospital rehospitalizations within 30 days represent a burden for patients and the healthcare system. Improving the care during the hospital discharge period could decrease the risk of avoidable rehospitalizations. To describe the methods of our trial aiming to define the efficacy of a tailored transition program in patients with high risk for rehospitalization compared to the usual discharge procedure with the endpoint of 30 day rehospitalization rate. Pragmatic, randomized, open-label, single-center superiority trial with a follow-up of 30 days. Included are adult patients hospitalized in an acute internal medicine department who are planned to be discharged home with a high estimated risk (20% or more) of 30-day rehospitalization. Patients in the intervention group will receive individualized and coordinated discharge management by an interdisciplinary team, compared to usual care in the control group. The multimodal intervention includes individualized pre-discharge, bridging, and post-discharge intervention components. Before enrolling the first patient, the trial was prospectively registered at the ISRCTN registry (registration date April 4th 2023) under the number ISRCTN11162162 and was approved by the ethical committee (Ethikkommission Nordwest- und Zentralschweiz (EKNZ), ID 2022–01040). This trial aims to assess the efficacy of a well-defined multicomponent discharge intervention to reduce unplanned rehospitalization rates in high-risk patients.

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