Structured, Nurse‐Led Post‐Discharge Follow‐Up Calls to Reduce 30‐Day Hospital Readmissions: A Quality Improvement Initiative

ABSTRACT

Background

Thirty-day hospital readmissions remain a persistent challenge, undermining patient safety, disrupting care continuity, and straining healthcare system performance. Ineffective discharge education and weak care transitions leave patients vulnerable after hospitalization. Evidence suggests that structured follow-up calls within 24–72 h can reduce preventable readmissions and strengthen care transitions.

Aim

This study aimed to evaluate the effectiveness of structured, nurse-led follow-up telephone calls, guided by the AHRQ RED Toolkit, in reducing 30-day hospital readmissions.

Methods

This study was conducted in a 200-bed urban medical center. It was reviewed and classified as a quality improvement initiative with minimal ethical risk and did not require informed consent. Over a 12-week implementation period, registered nurses used a standardized script to conduct follow-up calls within 24–72 h of discharge. Calls addressed health status, medication use, follow-up appointments, and home support. Pre- and post-intervention readmission data were collected from the electronic health record. Analysis included descriptive statistics and Chi-square testing.

Results

Among 287 patients who received standard care, 17% were readmitted within 30 days of discharge. In contrast, only 3.5% of 112 patients who received structured follow-up calls were readmitted, representing an absolute reduction of 13% (χ ² = 12.05, p = 0.0005). Patients also reported improved satisfaction and confidence in managing their care.

Linking Evidence to Action

Structured, nurse-led post-discharge follow-up telephone calls within 24–72 h should be integrated into standard discharge workflows to reduce preventable hospital readmissions. Nursing leadership can leverage this low-cost, scalable intervention to strengthen transitional care, improve patient safety, and support value-based care outcomes across diverse healthcare settings.

Conclusions

Nurse-led post-discharge follow-up calls significantly reduced 30-day readmissions while enhancing patient safety and care transitions. Findings support incorporating structured follow-up calls into standard discharge planning as a cost-effective, evidence-based intervention for broad implementation.