Combined discharge interventions significantly reduced 30-day readmissions in frail older patients, whereas patients not receiving them had 26.1 times higher odds of readmission.
Do combined transitional care interventions reduce 30-day hospital readmissions in frail older patients aged ≥65 years?
An integrated discharge model combining nurse case management, telephone follow-up, early home care, and social worker support significantly reduces 30-day hospital readmissions in frail older adults.
Background and Objectives: Thirty-day hospital readmissions are a major clinical and economic challenge, particularly among frail older patients. Integrated protected discharge models, coordinated by nurse case managers and including multidimensional hospital-to-community interventions, may improve continuity of care and reduce inappropriate readmissions. Materials and Methods: We conducted a retrospective observational study on 200 consecutive patients aged ≥65 years, discharged between January and December 2024 from a public hospital in Italy. Frailty was assessed using BRASS scores (≥11), ADL, and IADL. The primary outcome was 30-day hospital readmission. Logistic regression models evaluated the impact of individual interventions (Model 1) and combined interventions (Model 2), defined as the simultaneous presence of four components: nurse case manager involvement, telephone follow-up, activation of home care (ADI) within 24 h, and social worker support. Results: Overall, 65 patients (32.5%) were readmitted within 30 days. In the multivariate analysis, nurse case manager involvement was associated with lower odds of readmission (OR = 0.023; 95% CI 0.008–0.064; p < 0.001). Early ADI activation was not associated with readmission in the bivariate analysis (p = 0.195) but showed higher odds of readmission in the multivariable model (OR = 3.475; 95% CI 1.384–8.725; p = 0.008). The combined interventions variable was significantly associated with readmission in Model 2. Patients who did not receive combined interventions had higher odds of 30-day hospital readmission compared with those who did (OR = 26.1; 95% CI 10.1–67.5; p < 0.001). Conclusions: An integrated protected discharge model coordinated by a nurse case manager and including combined interventions was associated with lower odds of 30-day hospital readmission among frail older patients. These findings suggest that the potential benefit of transitional care may lie not in isolated interventions but in the multidimensional integration and coordination of clinical, functional, and social support strategies, highlighting the central role of nurse case managers in transitional care pathways.
Azzellino et al. (2026) studied this question. Combined discharge interventions significantly reduced 30-day readmissions in frail older patients, whereas patients not receiving them had 26.1 times higher odds of readmission.