Reduced Hospital Readmissions Through Personalized Care: Implementation of a Patient, Risk-Focused Hospital-Wide Discharge Care Center.

Hospital readmission remains a common and costly event. For patients, hospital readmission is often associated with adverse outcomes in the short and long term. Despite broad interest in reducing hospital readmissions and the implementation of a wide range of programs to combat unplanned preventable readmissions, progress has been challenging. Multipronged, complex interventions have demonstrated effectiveness in published studies, yet they typically target a particular patient population (e.g., older adults), condition (e.g., heart failure), or hospital unit and are seldom implemented at the whole-hospital level. There is a pressing need for implementation studies of hospital-wide, comprehensive discharge care interventions. This article describes the design and first 2 years of implementation of the Discharge Care Center (DCC), a hospital-wide intervention designed to reduce readmissions at Vanderbilt University Hospital. Structured around a nurse-led Triage Team and a multidisciplinary Care Coordination Team specialized in post-discharge response to patient needs, the DCC utilizes a combination of automated surveillance and risk-based support to provide comprehensive and personalized coverage to adult patients discharged from the hospital to home. In its first 2 years of implementation, the DCC has cared for patients after 80,247 hospital discharges, providing 57,352 clinically relevant interventions. Vanderbilt University Hospital has seen a highly promising impact on readmissions, from a baseline (July 2019-June 2021) monthly mean 30-day unplanned readmission rate of 10.6% to a new rate of 9.9%, sustained for 2 consecutive years (July 2021-October 2023). This article presents the key functions of the DCC, the forms of implementation adopted, and practical advice for other healthcare systems aiming to implement a successful discharge care intervention at scale.