Communication and integration could help decrease the likelihood of hospital readmission, data from the OPTIMAL project in Croydon suggest.
OPTIMAL aims to optimise hospital patients’ follow-up processes, especially during the first month after discharge. The goal is to reduce readmissions by 5 per cent within the first year of its installation and improve the process by means of patient satisfaction.
Data from the project are presented in a study published in BMJ Open. The study forms the user requirements phase of the project, investigating the needs and characteristics of patients who had been admitted to Croydon University Hospital (CUH), London, for two or more times in the past 12 months.
A total of 347 patients responded to a postal questionnaire, a response rate of 12.7 per cent.
The number of admissions in the past 12 months ranged from two to 30, with a mean of 2.8.
At discharge, 72.4 per cent of patients were not given a contact for out-of-hours help.
Regression analysis identified patient factors that were significantly associated with frequent admissions (more than two in 12 months), which included age (P=.008), being in receipt of care (P=.005) and admission due to a fall (P=.01). Receiving polypharmacy was not a significant factor.
Post-discharge, 41.8 per cent of patients were concerned about being readmitted to the hospital.
In the first 30 days after discharge, over half of patients (54.5%) received no contact from a health care professional.
The authors said: “Considering that social care needs were more of a determinant of admission risk than medical needs, rectifying the lack of integration, communication and the under-utilisation of existing patient services could prevent avoidable problems during the transition of care and help decrease the likelihood of hospital readmission.”
