Every year, thousands of patients leave the hospital only to face preventable setbacks at home. The moment of discharge marks a critical crossroad: if the transition isn’t handled properly, recovery can stall, complications can arise, and the risk of returning to the hospital climbs.
The Scope of the Readmission Problem
Discharge may feel like the finish line, but for many patients, especially those with complex wounds, chronic conditions, or multiple medications, it’s the beginning of the next phase of care.
National data shows that about 14% of patients are readmitted within 30 days of discharge. For older adults and those with chronic or high-risk conditions, that rate can rise to 17% or more. Certain diagnoses, such as blood-related diseases, can see rates exceed 20%. These readmissions don’t just impact patients, they strain health care systems and cost billions annually.
These numbers show that discharge is not simply the end of hospital care, it’s the pivot toward home recovery, and many discharge plans fall short.
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What “Safe Discharge” Really Means
At Restore First Health (RFH), our Safe Discharge process ensures that patients leave the hospital with the right plan, support, and follow-up.
Our approach includes:
- Timely follow-up: Within 48–72 hours of leaving the hospital, our mobile clinical teams engage the patient at home.
- Advanced wound care & monitoring: Tracking infection signs, ensuring proper dressing changes, and addressing factors that delay healing.
- Care coordination: Hospital teams, case managers, home health, and RFH clinicians collaborate to ensure the next steps are clear.
- Patient & caregiver education: Reviewing medications, warning signs, and home care instructions in plain language.
- Home environment assessment: Checking for safety, accessibility, and cleanliness to support recovery.
- Proactive risk mitigation: Identifying and addressing common causes of readmission such as infection, falls, or medication confusion.
Watch: Why Safe Discharge Matters | Healing Faster & Safer at Home with Restore First Health
Why It Matters: The Costs and Consequences
When safe discharge is not executed effectively, the consequences go far beyond frustration. Patients who are readmitted often face longer hospital stays, more complications, and a reduced quality of life.
For hospitals, higher readmission rates can lead to penalties and decreased performance ratings. And for the health care system, avoidable readmissions represent billions in wasted costs each year.
In short: investing in safe discharge yields returns in better outcomes, lower costs, and fewer hospital returns.
How RFH’s Safe Discharge Process Works (Step-by-Step)
- Pre-Discharge Planning: The discharge team identifies patient risks and flags those who need home-based or advanced wound care.
- Handoff to RFH Mobile Team: RFH receives the referral and schedules a home visit within 48–72 hours.
- Initial Home Visit: A mobile clinician evaluates wounds, checks vital signs, reviews medications, and educates the patient and caregiver.
- Ongoing Home Monitoring: Our nurse practitioners monitor the patient’s wound or chronic condition and maintains communication with hospitals and home health.
- Outcome Review: Once recovery milestones are met, the patient transitions back to standard outpatient or home health care.
This structured approach ensures that the patient isn’t left to fend for themselves once they leave the hospital.
Evidence That Follow-Up Matters
Patients who receive timely follow-up care after discharge experience fewer complications and lower readmission rates. The presence of a post-discharge plan, especially one that includes home-based visits and education, can make the difference between continued healing and a return to the hospital.
Common Pitfalls in Discharge That RFH Helps Avoid
- Poor wound management: Our mobile team monitors, cleans, and protects wounds.
- Medication confusion: Clinicians review prescriptions and ensure understanding.
- Lack of caregiver support: RFH educates both patient and family in the home.
- Delayed follow-up: We visit within 48–72 hours to prevent any gaps/delays in care.
By proactively addressing these issues, we keep recovery on track and patients healing safely in the place they call home.
The Future of Healing Starts at Home
A successful discharge isn’t just a patient leaving the hospital, it’s a patient stepping confidently into recovery. By ensuring a safe, well-coordinated transition from a nursing home or hospital to home, we can prevent avoidable readmissions and redefine healing beyond hospital walls.
If you or a loved one are in need of safe discharge or care at the bedside, request a consult today to learn how Restore First Health can help.
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Centers for Disease Control and Prevention (CDC). (2024). Chronic Disease Readmission Data and Hospital Burden. Retrieved from https://www.cdc.gov/pcd/issues/2024/24_0138.htm
Agency for Healthcare Research and Quality (AHRQ). (2022). Trends in Hospital Readmissions, 2016–2020. Healthcare Cost and Utilization Project (HCUP) Statistical Brief #304. Retrieved from https://hcup-us.ahrq.gov/reports/statbriefs/sb304-readmissions-2016-2020.jsp
Centers for Disease Control and Prevention (CDC). (2015). Hospital Readmissions Among Older Adults in the United States. National Health Statistics Reports No. 84. Retrieved from https://www.cdc.gov/nchs/data/nhsr/nhsr084.pdf
Centers for Medicare & Medicaid Services (CMS). (2023). Hospital Readmissions Reduction Program (HRRP). Retrieved from https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp
BMC Public Health. (2021). Socioeconomic Factors and Readmission Rates: Analysis of U.S. Hospital Data. Retrieved from https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11987-z