Discharge planning and home follow-up for elderly hospital patients could prevent readmission.

Within a context where the demand for home care is increasing far more quickly than the supply, it is all the more important to base decisions and priorities on the best available evidence. Scientific studies show that planning the hospital discharge of elderly patients reduces the risk of readmission, especially when the planning extends from the hospital to the home. Proper discharge planning, accompanied by home follow-up, could also help the elderly person to function more independently on returning home after a visit to the emergency. An evaluation of the patient’s overall health by a specialized nurse, along with follow-up home care, could also enhance autonomy in carrying out daily activities.

The disabilities of elderly patients with long term needs could be reduced.

The disabilities of elderly patients with long term needs could be reduced by assigning a specific health care professional to the patient to coordinate services and health care that he or she receives or needs to receive.

Further research is needed to evaluate the effectiveness of this intervention on patients’ health and on their caregivers, and the cost to the health system. More studies are also required to determine the which elements of the intervention are key to ensuring their success, such as the duration of follow-up home care services provided by the health professional.

Main researcher

André Tourigny, INSPQ (Hôpital Saint-Sacrement)


Research report

Call for proposals

Deposit of the research report: April 2011