Patient-Centred Discharge Planning and Its Effect on Hospital Readmission Rates in Adults: A Systematic Review

Background to Discharge Planning

Discharge planning is the development of an individualised plan for each patient before they leave hospital, with the aim of containing costs, improving outcomes and ensuring that the patient is discharged at the right time with appropriate support (Gonçalves-Bradley et al., 2022). It usually includes assessment of needs, development of the plan, its implementation and monitoring. Patient-centred approaches involve the patient and family in each of these stages, so that the plan reflects their priorities, abilities and home circumstances.

Readmission rates show the scale of the problem. In a landmark analysis of almost 12 million Medicare patients in the United States, Jencks et al. (2009) found that 19.6% were readmitted within 30 days of discharge. Half of the patients readmitted after a medical admission had no recorded visit to a doctor between discharge and readmission, suggesting that follow-up after hospital was often missing. The estimated cost of unplanned readmissions to the Medicare programme in 2004 was 17.4 billion dollars.

Not every readmission is preventable, and some reflect the natural course of serious illness. However, the findings of Jencks et al. (2009) prompted health systems in many countries to measure readmission and to invest in discharge planning and transitional care. Because older adults with multiple long-term conditions are at the highest risk, much of the research has focused on this group, and many of the most successful programmes have been led by nurses.

Search Strategy and Methods

Evidence for this example was identified through targeted searches of openly accessible bibliographic records, publisher websites and the reference lists of key reviews. Search terms combined keywords for the intervention (“discharge planning”, “transitional care”, “care transitions”, “handover”) with terms for outcomes and approach (“readmission”, “rehospitali*”, “patient-centred”, “nurs*”), joined with the Boolean operators AND and OR. A full systematic review for assessment would run the same strategy in CINAHL, PubMed/MEDLINE, the Cochrane Library and Embase and report the number of records screened in a PRISMA flow diagram.

Sources were eligible if they evaluated discharge planning or transitional care interventions for adults leaving hospital and reported readmission as an outcome, or if they provided key evidence on the scale of readmission. Randomised controlled trials and systematic reviews of trials were prioritised. Studies of children, mental health admissions and discharges to long-term care only were excluded, as were studies without a readmission outcome.

Six sources published between 1999 and 2022 were included: two randomised controlled trials, three systematic reviews (one a Cochrane review) and one large observational study (Table 1). The two older trials were retained because they established the nurse-led models still used in practice. Each source was appraised using the Critical Appraisal Skills Programme (CASP) checklist appropriate to its design, and findings on discharge planning were synthesised narratively and grouped into themes.

Key Findings on Discharge Planning

Three themes were identified: the overall effect of structured discharge plans on readmission, the features that make interventions more effective, and the contribution of nurse-led and patient-centred transitional care. Table 1 summarises the included sources.

Author, year	Design	Setting and sample	Key finding
Naylor et al. (1999)	Randomised controlled trial	363 older adults; two Philadelphia hospitals	Advanced practice nurse discharge support and home follow-up; readmission at 24 weeks 20.3% vs 37.1%.
Coleman et al. (2006)	Randomised controlled trial	750 older adults; Colorado	Transition coach and self-management support; 30-day readmission 8.3% vs 11.9%.
Jencks et al. (2009)	Retrospective observational study	11.9 million Medicare patients; United States	19.6% readmitted within 30 days; half had no doctor visit before readmission.
Hesselink et al. (2012)	Systematic review	36 RCTs of hospital-to-primary-care handover	25 of 36 trials showed benefit; effective components included medication reconciliation and shared follow-up.
Leppin et al. (2014)	Systematic review and meta-analysis	42 RCTs of readmission interventions	30-day readmission reduced by 18% (RR 0.82); complex, self-care-focused interventions more effective.
Gonçalves-Bradley et al. (2022)	Cochrane systematic review	33 RCTs, 12,242 participants	Discharge plans probably reduce length of stay slightly and readmission at three months (RR 0.89).

Theme 1: The Effect of Discharge Planning on Readmission

The most comprehensive evidence comes from the Cochrane review by Gonçalves-Bradley et al. (2022), which included 33 randomised trials and 12,242 participants. Compared with usual care, a structured discharge plan tailored to the individual patient probably led to a small reduction in the initial length of hospital stay, by around three-quarters of a day, and a small reduction in readmissions over about three months (risk ratio 0.89). There was little or no difference in mortality, and patient satisfaction may have improved, although the certainty of this finding was very low.

A broader meta-analysis by Leppin et al. (2014) examined 42 randomised trials of interventions designed to prevent early readmission, many of which included discharge planning as a component. Overall, these interventions reduced the risk of readmission within 30 days by 18% (relative risk 0.82). The effect was consistent across different patient groups, suggesting that well-designed discharge and transitional support can reduce readmission in a range of adult populations.

These findings indicate that discharge planning produces modest but worthwhile benefits. A relative reduction of 11% to 18% may seem small, but given how often patients are readmitted, the absolute number of readmissions avoided across a hospital can be substantial. The effects also appear larger in some trials than others, which raises the question of which components matter most.

It is also worth noting how readmission was measured. Most trials counted any unplanned return to hospital within a fixed period, regardless of the reason, and few distinguished between readmissions that could have been prevented and those caused by new or unrelated problems. Some trials relied on hospital records from a single site, which may have missed readmissions to other hospitals. These differences make it difficult to compare results directly and may partly explain why the size of the benefit varied so much between studies.

Theme 2: What Makes Discharge Planning More Effective?

Leppin et al. (2014) explored which features were associated with greater effect. Interventions with more components were around 1.4 times more effective than simpler ones, and those that involved more people in delivering care, or that supported patients’ capacity for self-care, were around 1.3 times more effective. Trials published before 2002 reported larger effects than more recent ones, possibly because usual care has improved over time. The authors concluded that effective interventions tend to be complex and to support patients and carers after they leave hospital.

A systematic review of 36 randomised trials by Hesselink et al. (2012) reached similar conclusions about the handover from hospital to primary care. Most trials tested multicomponent interventions, and 25 showed significant benefits. Effective components included medication reconciliation, structured electronic discharge summaries, discharge planning, shared follow-up between hospital and community providers and timely communication with general practitioners. However, the variety of interventions prevented the authors from identifying which single components were responsible.

Together, these reviews suggest that discharge planning works best when it is not a single event on the day of discharge but a process that begins early, involves several professionals, communicates clearly with community services and continues after the patient has gone home. This view is consistent with the definition used in the Cochrane review, which describes the planning of discharge as a process of assessment, planning, implementation and monitoring (Gonçalves-Bradley et al., 2022).

Theme 3: Nurse-Led and Patient-Centred Transitional Care

Two influential trials show what nurse-led programmes can achieve. In a randomised trial of 363 older adults in Philadelphia, Naylor et al. (1999) tested comprehensive discharge planning by advanced practice nurses, with home visits and telephone follow-up for four weeks after discharge. At 24 weeks, 20.3% of patients in the intervention group had been readmitted, compared with 37.1% in the control group, and multiple readmissions and costs were roughly halved. This model later became known as the Transitional Care Model.

Coleman et al. (2006) tested a patient-centred approach in a randomised trial of 750 older adults in Colorado. Patients were supported by a transition coach, often a nurse, who helped them manage their own medicines, keep a personal health record, arrange follow-up appointments and recognise warning signs. Readmission at 30 days was 8.3% in the intervention group compared with 11.9% in the control group, and at 90 days it was 16.7% compared with 22.5%. The intervention focused on building patients’ confidence and skills rather than doing things for them.

Both trials targeted older adults with complex needs, who are at the highest risk of returning to hospital. They shared several features: a named professional who followed the patient across the transition, a focus on medicines, early follow-up with community services and clear advice on what to do if symptoms worsened. These features match the components identified as effective in the systematic reviews (Hesselink et al., 2012; Leppin et al., 2014), which strengthens confidence that they contribute to the observed reductions in readmission.

Discussion

This review shows that discharge planning reduces readmission, but that the size of the benefit varies widely. Structured discharge plans alone produce small reductions (Gonçalves-Bradley et al., 2022), whereas more intensive, nurse-led programmes that continue after discharge have reported much larger effects (Naylor et al., 1999; Coleman et al., 2006). The difference appears to lie in the continuity of support across the transition from hospital to home, rather than in the discharge plan itself.

The evidence also highlights the importance of patient-centred care. Interventions that strengthened patients’ capacity for self-care were more effective (Leppin et al., 2014), and the Care Transitions Intervention achieved its results by coaching patients rather than managing their care for them (Coleman et al., 2006). This suggests that discharge planning should aim to prepare patients and carers to take control, with nurses acting as teachers and coaches as well as coordinators.

However, the finding that more recent trials show smaller effects deserves attention. As usual care has improved, and as readmission has become a performance measure, the added value of new discharge planning interventions may be smaller than early trials suggested. Health systems also differ, so models developed in the United States may not transfer directly to the United Kingdom or other countries with different community services. Local adaptation and evaluation are therefore essential.

The role of family carers also deserves greater attention. Many older patients depend on relatives to collect medicines, attend appointments and notice when their condition changes, yet carers are often given information only at the last minute or not at all. Several of the effective programmes involved carers directly, and the post hoc analysis by Leppin et al. (2014) suggested added value from support that included caregivers. Including carers in teaching and in the plan for follow-up is a simple step that nurses can take on every ward, and it is consistent with patient-centred care.

The evidence base has limitations. Many trials were conducted with older adults in the United States, and interventions varied considerably in content and intensity, making comparison difficult. Readmission is an imperfect outcome, since some readmissions are appropriate. This review relied on openly accessible, English-language sources and did not involve independent double screening. Future research should test patient-centred discharge planning in different health systems and include outcomes that matter to patients, such as confidence, function and quality of life.

Implications of Discharge Planning Evidence for Practice

For adult nurses, the evidence on discharge planning supports starting the process at admission, involving patients and carers in setting goals, and assessing medicines, mobility, home circumstances and support needs early. Before discharge, nurses should reconcile medicines, teach patients about their treatment and warning signs using teach-back, ensure follow-up appointments are arranged and send clear information to community teams. For patients at high risk of readmission, nurse-led telephone calls or visits after discharge offer additional benefit.

Day-to-day ward routines matter too. Nurses should record an expected date of discharge early in the admission, review it daily with the patient and the wider team, and escalate delays such as awaited equipment, transport or care packages so that patients do not leave in a rush at the end of the day without the preparation they need.

Managers should support multidisciplinary discharge teams, structured discharge summaries and links with community services. Planning for discharge connects closely with other aspects of care: nutritional screening identifies patients who need dietary support at home, prompt recognition of infection through the Sepsis Six can prevent early readmission, and patients on enhanced recovery pathways need well-prepared discharge plans to leave hospital safely. Patients with type 2 diabetes also benefit from clear plans for medicines and monitoring.

Conclusion

This systematic review examined the effect of patient-centred discharge planning on readmission among adults leaving hospital. The evidence shows that structured discharge planning produces modest reductions in readmission and length of stay, and that more intensive, nurse-led transitional care programmes that continue after discharge can achieve larger benefits, particularly for older adults at high risk.

The most effective approaches are multicomponent, begin early, involve patients and carers as active partners and continue support beyond the hospital door. Nurses are central to each of these elements, and strengthening their role in preparing patients for home and in transitional care offers a practical way to make the move from hospital to home safer for patients and their families.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. https://doi.org/10.1001/archinte.166.17.1822

Gonçalves-Bradley, D. C., Lannin, N. A., Clemson, L., Cameron, I. D., & Shepperd, S. (2022). Discharge planning from hospital. Cochrane Database of Systematic Reviews, (2), CD000313. https://doi.org/10.1002/14651858.CD000313.pub6

Hesselink, G., Schoonhoven, L., Barach, P., Spijker, A., Gademan, P., Kalkman, C., Liefers, J., Vernooij-Dassen, M., & Wollersheim, H. (2012). Improving patient handovers from hospital to primary care: A systematic review. Annals of Internal Medicine, 157(6), 417–428. https://doi.org/10.7326/0003-4819-157-6-201209180-00006

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418–1428. https://doi.org/10.1056/NEJMsa0803563

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., Wang, Z., Erwin, P. J., Sylvester, T., Boehmer, K., Ting, H. H., Murad, M. H., Shippee, N. D., & Montori, V. M. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095–1107. https://doi.org/10.1001/jamainternmed.2014.1608

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613–620. https://doi.org/10.1001/jama.281.7.613