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 preventable unplanned readmissions, progress has been challenging. Multipronged, complex interventions have demonstrated effectiveness in published studies, but 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. This article describes the design and the 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 triage team of nurses and a multidisciplinary care coordination team specialized in postdischarge response to patient needs, the DCC uses 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%, which was 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 health care systems aiming to implement a successful discharge care intervention at scale. Vanderbilt University Hospital implemented comprehensive postdischarge monitoring and care for all patients and achieved a sustained reduction in unplanned 30-day readmissions.