JMIR Publications

ABSTRACT

Unplanned emergency department (ED) visits and hospital readmissions post-discharge pose challenges for healthcare systems. Post-discharge telephone calls may improve care transitions, but their impact on hospital utilization remains unclear. A multi-center pragmatic quasi-randomized trial was conducted to evaluate the effectiveness of a nurse-led post-discharge telephone intervention implemented by Fraser Health Virtual Care (FHVC) in reducing ED visits and hospital readmissions. The trial included discharged participants at high-risk of re-admission. The intervention group received a structured nurse-led call 48 hours following their discharge from hospital, while the control group received standard care. Primary outcomes were ED visit and hospital readmissions within 7- and 30-days post –discharge call. Post-discharge calls significantly reduced ED visits at 7-days (incident rate ration [IRR] = 0.719, p < .001) and 32-days (IRR = 0.878, p = .024). No significant reductions in readmissions were observed. Structured post-discharge calls effectively reduce short-term ED utilization, but do not impact readmission rates, highlighting the need for additional interventions.