How to prevent readmission after discharge from the hospital? The challenge of the first 30 days

Post-hospital discharge: why is the first month after discharge the most critical? Discover home healthcare protocols to reduce readmissions

Leaving the hospital is always a delicate moment. When the hospital door closes behind a discharged patient, it marks the beginning of one of the most vulnerable and critical periods of the entire care pathway. The first 30 days after hospital discharge represent a window of time when the risk of complications, readmissions, and clinical deterioration reaches its peak, transforming what should be a time of joy and return to normalcy into a period of anxiety and uncertainty for patients and families.

Some data on readmissions in Switzerland: a clinical and economic problem

Epidemiological data reveal a concerning trend in the hospital-to-home transition. According to the Federal Statistical Office, in Switzerland, over 15% of patients older than 65 are readmitted to the hospital within 30 days of discharge, with rates reaching 22% for certain high-risk groups. These figures are more than just cold statistics; they represent human stories of preventable suffering, families in distress, and a healthcare system that struggles to maintain continuity of care once patients leave the hospital.

The issue of early readmissions is not only a clinical concern but also a significant economic challenge. The Organization for Economic Cooperation and Development (OECD) estimates that avoidable readmissions within 30 days cost the Swiss healthcare system over 400 million francs annually. These direct expenses are further increased by indirect costs that are hard to measure but equally real: loss of trust in the healthcare system, psychological effects on patients and their families, reduced quality of life, and decline in the functional independence of the elderly.

The problem of post-discharge has been further amplified by changes in the healthcare system over the last few decades. Economic pressure on hospital costs has led to a gradual reduction in the average length of hospital stays, with increasingly early discharges transferring a significant part of the healing process from the controlled hospital environment to the home environment, which is often unprepared to accommodate patients who are still fragile and in need of intensive care.

In this context, CAD Healthcare has developed an innovative and systematic approach to post-hospital discharge management, based on evidence-based protocols, advanced monitoring technologies, and an intensive home healthcare model that transforms the patient’s home into a safe and controlled extension of the hospital environment. Dynamic and timely organization is often essential to providing continuity of care for frail and complex patients.

Find out more about the advantages of home healthcare over hospitalization

How to manage the hospital-to-home transition to avoid readmission

The hospital-to-home transition should not be seen as a simple logistical transfer of the patient from one place to another, but as a complex clinical process requiring careful planning, multidisciplinary coordination, and intensive monitoring. Only through this systematic approach can we ensure that returning home truly represents the beginning of a new phase of well-being and not the prelude to new complications and avoidable suffering.

Returning home requires planning and contact to be made before the date of discharge. This is because there can often be significant clinical changes that determine the interventions required:

• planning of weekly interventions,
• involvement of external professionals,
• managing medications and medical equipment,
• possible adaptation of architectural barriers.

Most common causes of hospital readmission

Epidemiological analysis of hospital readmissions within 30 days of discharge reveals a significant phenomenon affecting all healthcare systems in developed countries, with Switzerland being no exception to this global trend.

Advanced age

Demographic factors play a key role in risk stratification. Advanced age is the strongest predictor, with each decade of life beyond 65 increasing the risk of readmission by 15%. Women show a slightly higher risk, probably related to greater longevity and the consequent higher prevalence of multiple comorbidities.

Clinical frailty

Clinical factors represent the most powerful and clinically relevant group of predictors. The number of comorbidities present at discharge correlates directly with the risk of readmission.

Polypharmacy and drug interactions

Polypharmacy emerges as a particularly relevant independent risk factor in the geriatric population. Patients taking 5-9 medications have an increased risk of readmission. This highlights not only the clinical complexity of these patients but also the challenges associated with treatment adherence and the risk of drug interactions in the home setting.

Social and economic conditions

Socioeconomic factors have a significant impact on readmission rates, reflecting inequalities in access to care and post-discharge support.

Early hospital discharge and subsequent readmissions

The phenomenon of early hospital discharge, accelerated by economic pressures on the healthcare system and cost-containment policies, has contributed significantly to the increase in readmission rates observed in recent decades.

While this reduction in hospital stays is a legitimate goal of economic efficiency, it has shifted a significant part of the healing process from the controlled hospital environment to the home environment, which is often unprepared to accommodate patients who are still in the process of clinical stabilization.

The situation is particularly critical for patients discharged during weekends or holidays, who have a 30% higher re-admission rate than those discharged on weekdays. This reflects the reduced availability of local services during weekends and the resulting difficulty in organizing appropriate follow-up care in the days immediately following discharge.

Early readmissions: a cost to the Swiss healthcare system

The economic impact of early readmissions on the Swiss healthcare system is considerable and growing. The financial analysis conducted by the Federal Office of Public Health estimates that avoidable readmissions within 30 days generate direct costs of over CHF 420 million per year, equivalent to 2.3% of total National Healthcare Spending. These costs are unevenly distributed among the cantons, with Ticino contributing around 28 million Swiss francs per year, reflecting both its population size and higher average age.

The social impact of early readmissions

The social impact of readmissions extends far beyond the economic dimension, involving often underestimated psychological, family, and community aspects. Patients who experience early readmissions show significantly higher levels of anxiety, depression, and loss of trust in the healthcare system.

Families and caregivers experience these events as personal failures, developing feelings of guilt and inadequacy that can compromise their ability to provide effective support during subsequent episodes of care. Qualitative research conducted on families who have experienced early readmissions reveals recurring patterns of frustration, confusion, and feelings of abandonment by the healthcare system.

The testimonies collected highlight how the following factors contribute significantly to the psychological distress of patients and families:

• lack of clear information,
• discontinuity in communication between the hospital and the community
• the absence of clear points of reference during the post-discharge phase

CAD protocols for hospital-to-home transition: an innovative model

CAD Healthcare has developed a revolutionary approach to post-hospital discharge management based on the concept of “post-acute hospital-at-home healthcare,” a model that transforms the patient’s home into a controlled and safe extension of the hospital environment. This care philosophy is based on three fundamental pillars: clinical continuity, intensity of monitoring, and personalization of intervention.

Clinical continuity in care

The first pillar, clinical continuity, ensures that there is no break in continuity between hospital and home healthcare. Our protocol requires the CAD team to contact the patient at least 48 hours before hospital discharge through a “pre-discharge” process that includes:

• clinical assessment of the patient while still in hospital,
• review of medical records,
• planning of the home healthcare plan
• preparation of the home environment to accommodate a patient in post-acute recovery.

Advanced telemonitoring

The second pillar, Advanced Telemonitoring, is based on the use of advanced technologies that allow continuous surveillance of the patient’s vital signs and clinical status during the first 30 days after discharge. This monitoring is not passive, but active and predictive, using artificial intelligence algorithms to identify early signs of clinical deterioration and activate preventive interventions before acute complications develop.

Personalized care plans

The third pillar, personalization of care, recognizes that each patient has specific needs related to their clinical condition, social context, and individual preferences. Our approach involves individual risk stratification and the development of personalized care plans that take into account not only clinical aspects, but also available family resources, home characteristics, and patient preferences regarding care modalities.

The pre-discharge protocol: setting the stage for success

The hospital-to-home transition process begins well before the patient leaves the hospital. Our pre-discharge protocol is a crucial step that largely determines the success of the entire post-discharge journey.

• The pre-discharge assessment is conducted by a CAD coordinator who visits the hospital to meet with the patient, family members, and hospital team. During this visit, detailed information is gathered on the clinical course of the hospitalization, current therapies, functional status, cognitive status, and any newly emerging limitations.
• The planning and updating of the home healthcare plan takes place before the patient’s discharge. In this way, CAD ensures adequate continuity of care so that all colleagues are aware of the information relating to the hospital stay and the respective continuation of care.
• Preparing the home environment is an often-overlooked but crucial aspect of a successful transition. Our technical team conducts a home visit to assess the safety of the environment, identify any new architectural barriers, and install the necessary monitoring technologies. This includes positioning environmental sensors, configuring telemonitoring devices, and verifying the internet connectivity required for the system to function. Learn more about how to plan post-hospitalization home healthcare in all its logistical and organizational aspects

Specific protocols for each condition

Recognizing that different clinical conditions present specific challenges in the post-discharge phase, CAD Healthcare has developed specialized protocols for the conditions most frequently associated with early readmission. These protocols integrate the best available scientific evidence with clinical experience gained in the field and the specificities of the home setting. Here are some examples:

• The Heart Failure Protocol is based on the guidelines of the European Society of Cardiology and includes daily monitoring of body weight, blood pressure, and oxygen saturation, with automated algorithms that identify early signs of decompensation. The protocol also provides specific education for patients and family members on warning signs, optimization of diuretic therapy based on telemonitoring data, and close coordination with the treating cardiologist for timely therapeutic adjustments. Together with the critical care nurse, joint follow-up and discussion of clinical cases are planned.
• The COPD Protocol focuses on monitoring respiratory function through respiratory function monitoring, reference parameters such as SpO2, sleep quality assessment to identify sleep apnea, and proactive management of exacerbations through personalized action plans. The protocol also includes home respiratory rehabilitation programs. Joint follow-up meetings and discussions on clinical cases are planned together with the critical care nurse.
• The Diabetes Protocol integrates continuous blood glucose monitoring with personalized dietary education, management of acute complications such as severe hypoglycemia and ketoacidosis, and coordination with the diabetes team to optimize insulin therapy. Particular attention is paid to the prevention of chronic complications through regular screening and preventive interventions.
• The Post-Surgical Protocol focuses on the management of surgical wounds, prevention of infections, control of post-operative pain, and early functional rehabilitation. The protocol also includes thromboembolic risk assessment and implementation of appropriate preventive measures, as well as nutritional support to promote tissue healing. Regular follow-up visits are planned together with the wound care nurse.

Enabling Technologies for Hospital-to-Home Transition and Home healthcare

The effective implementation of hospital-to-home transition protocols requires the use of advanced technologies that enable continuous monitoring, two-way communication, and predictive analysis of clinical data. CAD Healthcare has invested significantly in the development and implementation of an integrated technology platform that represents the state of the art in the field of home telemedicine.

Integrated telemonitoring system

The Integrated Telemonitoring System combines wearable devices, environmental sensors, and mobile applications to create a comprehensive data collection ecosystem. Patients wear discreet devices that continuously monitor heart rate, heart rhythm, blood pressure, oxygen saturation, body temperature, and physical activity levels. This data are transmitted in real time to the CAD operations center, where it is analyzed by artificial intelligence algorithms and specialized clinical staff.

Graded response protocols: a warning system from alerts to emergencies

The intensive CAD monitoring system is integrated with graded response protocols that define specific actions for each type of alert generated by the system. These protocols have been developed based on the best available evidence and clinical experience, and are continuously updated through outcome analysis and feedback from clinical staff.

• For notification alerts, the system automatically documents the event in the electronic medical record and reports it to the nurse on duty and/or on call during the daily case review. These alerts include minor changes in vital parameters that are within normal ranges but show trends that could be clinically relevant over time.
• Attention alerts trigger a clinical assessment procedure that includes telephone contact with the patient by a nurse within 15 minutes of the alert being generated. During this contact, a structured symptom assessment is carried out and, if necessary, a home visit is scheduled to investigate the clinical situation further.
• Urgent alerts trigger the immediate activation of the CAD rapid response team, with a nurse arriving at the patient’s home within 20 minutes. This team is equipped with portable diagnostic devices such as a complete multiparameter monitor and a 5-lead ECG.
• Critical alerts simultaneously activate the CAD team and local emergency services, with coordination protocols that allow joint intervention when necessary. In these cases, the CAD operator acts as an information bridge between the patient and the emergency services, providing detailed clinical data that allows for optimal preparation of the intervention.

Customization of monitoring based on patient characteristics

Recognizing that each patient has specific needs related to their clinical condition, preferences, and social context, CAD Healthcare has developed customization algorithms that automatically adapt monitoring protocols to individual characteristics. This customization occurs at several levels: measurement frequency, alarm thresholds, types of sensors used, and alert communication methods.

• Disease-based customization uses specific protocols developed for different clinical conditions. For example, patients with heart failure receive more intensive monitoring of body weight and hemodynamic parameters, while patients with COPD have a greater focus on respiratory parameters and sleep quality.
• Risk-based personalization adapts the intensity of monitoring to the individual risk profile calculated using the CAD-RISK Score. High-risk patients receive continuous monitoring of all available parameters, while low-risk patients can benefit from less intensive protocols that still maintain a high level of safety.
• Preference-based personalization takes into account the individual preferences of the patient regarding monitoring and communication methods. Some patients prefer to receive continuous feedback on their vital parameters, while others find this information anxiety-provoking and prefer to be contacted only when necessary. The CAD system is flexible enough to adapt to these different preferences while maintaining high standards of clinical safety.

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Conclusions: controlled post-discharge to avoid early readmissions

The results presented in this article clearly demonstrate that post-hospital discharge management can be radically transformed through the implementation of innovative care models that integrate advanced technologies, evidence-based clinical protocols, and multidisciplinary coordination. CAD Healthcare’s experience is a concrete example of how the limitations of the traditional hospital-to-home transition model can be overcome, transforming what has historically been a moment of vulnerability and discontinuity into an opportunity for therapeutic consolidation and improved clinical outcomes. Every readmission avoided means a family that does not have to face the anxiety and stress of a new hospitalization, a patient who maintains their autonomy and dignity in their home environment, and a healthcare system that uses its resources more efficiently and effectively.

The CAD model demonstrates that the traditional dichotomy between hospital care and home healthcare can be overcome through the creation of a continuum of care that maintains the intensity and quality of hospital care while extending it into the home environment. This “post-acute hospital-at-home healthcare” represents an innovative paradigm that could revolutionize the organization of healthcare services in the coming decades.

The future evolution of post-discharge management will be characterized by increasingly sophisticated integration of emerging technologies that will further expand the possibilities of advanced home healthcare. Predictive artificial intelligence represents one of the most promising frontiers, with increasingly sophisticated algorithms that will be able to predict complications with increasing advance notice, allowing for increasingly early and effective preventive interventions.

The role of CAD as an “innovation laboratory” for the Ticino healthcare system is highlighted by its collaboration with academic and research institutions for the development of new technological solutions and organizational models. This research and development function contributes not only to the improvement of CAD services but also to the advancement of knowledge in the field of home healthcare at the national and international levels.

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FAQ – Hospital discharges and readmissions

How common is readmission within 30 days of discharge?

In Switzerland, more than 15% of patients over the age of 65 return to the hospital within 30 days of discharge, with higher rates among frail patients or those with chronic conditions.

How can I avoid returning to the hospital after discharge?

To reduce the risk of readmission, it is essential to clarify the treatment plan with your doctors, take your medication correctly, attend scheduled check-ups, activate a home healthcare service (Spitex or private) if necessary, and report any problems to your doctor immediately.

How are hospital discharges planned in Switzerland?

Swiss hospitals have discharge planning procedures, managed by nurses or social workers, which aim to coordinate the patient’s return home. This includes assessing clinical needs, communicating with the family doctor, arranging home healthcare services, and adapting the home environment.

What role does home healthcare play in preventing readmissions?

Home healthcare services (Spitex or recognized private providers) allow medication, therapy, physical therapy, and social support to be provided directly at home. This ensures continuity of care, reduces complications, and supports both the patient and their family.

Bibliography and References

• Federal Statistical Office. “Medical Statistics of Hospitals 2023: Discharges and readmissions.” Neuchâtel: UST, 2024.
• OECD Health Statistics 2024. “Healthcare Quality Indicators: Hospital Care.” Paris: OECD Publishing, 2024. Available at: https://www.oecd.org/health/health-data.htm
• National Association for Quality Development in Hospitals and Clinics (ANQ). “National Quality Report 2023: Re-admissions.” Bern: ANQ, 2024.
• Federal Office of Public Health. “Costs of the Swiss healthcare system 2023: Analysis by care sector.” Bern: FOPH, 2024.
• Coleman, E.A., et al. “The Care Transitions Intervention: Results of a randomized controlled trial.” Archives of Internal Medicine, vol. 166, no. 17, 2006, pp. 1822-1828.
• Shepperd, S., et al. “Hospital at home: home-based end-of-life care.” Cochrane Database of Systematic Reviews, 2021, Issue 3. Art. No.: CD009231.
• Burke, R.E., et al. “Moving beyond readmission penalties: creating an ideal process to improve transitional care.” Journal of Hospital Medicine, vol. 8, no. 2, 2013, pp. 102-109.