Hospital Discharge for Older People: Reducing Readmission Risk Through Practical Governance and Follow-Up
Reducing readmissions is a practical test of whether hospital discharge, step-down and admission avoidance pathways are genuinely safe and outcome-led. Many readmissions occur within days, driven by medication issues, deterioration that was not spotted early, poor equipment planning, or fragile informal support. For older people with dementia, readmission risk is amplified by delirium, distress and disrupted routines, making alignment with dementia service models and care pathways essential. Providers reduce readmission risk when they treat discharge as a managed transition with structured follow-up, not a single event.
Why readmissions happen: the recurring operational themes
Across community services and homecare, readmissions commonly link to:
- Medication errors: missing medicines, unclear changes, MAR mismatches
- Unrecognised deterioration: infection, dehydration, pain, delirium
- Falls and mobility risk: unsafe transfers, missing equipment, fatigue
- Insufficient early support intensity: support ramps up too slowly
- Communication breakdown: families and staff unclear on what to monitor
These are governance issues as much as care delivery issues. They are preventable when responsibilities, thresholds and follow-up are clear.
What “good discharge” looks like from a provider perspective
Discharge quality is demonstrated by:
- Clear understanding of baseline and current functioning
- A realistic short-term plan (first 72 hours) and a medium-term plan (two weeks)
- Confirmed medicines, equipment and escalation routes
- Documented consent/capacity decisions where relevant
- Active follow-up and review with decision points
Operational example 1: Medication reconciliation within 24 hours
Context: An older person returns home with multiple medication changes. The discharge summary is delayed or incomplete, and the pharmacy supply does not match the previous MAR chart. This is a high-risk point for readmission.
Support approach: The provider treats medicines reconciliation as a mandatory post-discharge control.
Day-to-day delivery detail: A senior staff member compares the discharge medicines list (or available discharge information) against the current MAR and the medicines physically present in the home. Any mismatch triggers immediate escalation through agreed routes. Staff document interim actions (e.g., hold a non-urgent dose pending confirmation) and record who was contacted and when. Where delegation or clinical oversight is required, the provider ensures competent staff review and sign-off rather than leaving the issue to frontline workers without support.
How effectiveness is evidenced: Evidence includes reconciliation logs, MAR amendments with reasons, audit outcomes, and reduced medication-related incidents in the post-discharge period.
Operational example 2: The “first 72 hours” intensive support model
Context: People are discharged with a standard visit pattern that does not reflect immediate post-discharge vulnerability, resulting in dehydration, missed meals, unmanaged pain, falls or delirium.
Support approach: The provider implements a standardised “first 72 hours” support uplift where indicated.
Day-to-day delivery detail: Support is increased temporarily to include additional welfare checks, hydration prompts, meal support and mobility assistance. Staff use a simple monitoring tool for red flags: increasing confusion, reduced urine output, inability to mobilise, unmanaged pain, shortness of breath, new swelling or fever. Families receive a clear explanation of what to watch for and how to escalate. If cognition is impaired, routines are kept stable and staff consistency is prioritised to reduce distress.
How effectiveness is evidenced: Evidence includes documented monitoring, reduced emergency calls, and review notes showing the uplift was safely stepped down or escalated appropriately.
Operational example 3: Equipment and moving-and-handling planning that prevents falls
Context: Discharge occurs before equipment is in place (commode, profiling bed, rail, hoist). Transfers become unsafe, leading to falls or carer injury.
Support approach: The provider uses pre-discharge confirmation and interim risk plans.
Day-to-day delivery detail: Before discharge, staff confirm whether equipment is required and when it will arrive. If equipment cannot be provided immediately, a temporary plan is documented: additional staff for transfers, restricted mobility with supervised toileting, rearranged furniture for clear routes, and time-limited increases in visits. Staff complete moving-and-handling updates and ensure the care plan is explicit about techniques and risks.
How effectiveness is evidenced: Evidence includes reduced post-discharge falls, updated moving-and-handling plans, and incident reviews showing proactive mitigation was used rather than reactive response.
Safeguarding, capacity and restrictive practice after discharge
Discharge planning must remain lawful. Where a person cannot consent to arrangements, capacity assessments and best-interests decisions must be recorded, with the least restrictive approach applied and reviewed. If restriction increases (e.g., limiting access to stairs due to falls risk), the rationale, review timeline and alternatives must be documented.
Commissioner expectation
Commissioner expectation: Commissioners expect providers to evidence reduced readmissions through measurable controls: medication reconciliation, early follow-up, escalation pathways, and learning from avoidable readmissions. Narrative claims are insufficient without operational data and audit trails.
Regulator / inspector expectation (CQC)
Regulator / inspector expectation (CQC): Inspectors will test whether discharge transitions are safe, coordinated and person-centred. They will examine medicines management, staff competence, risk management, and whether providers learn from incidents and prevent repeat harm.
Governance and improvement: the loop that reduces readmissions
Readmission reduction is sustained through:
- Weekly thematic review of post-discharge incidents and readmissions
- Audit of medicines reconciliation and escalation compliance
- Sampling of care records for decision-making quality
- Joint learning with system partners where patterns emerge
Where providers can show this loop operating, readmissions decrease not through luck, but through disciplined operational control.