Reducing Readmissions Through Effective Hospital to Home Care Transitions
Unplanned hospital readmissions are a key indicator of ineffective system transitions and poor continuity of care. For domiciliary care providers, the hospital-to-home interface represents a critical risk point where failures in information transfer, staffing readiness or medication management can quickly result in avoidable harm. Providers that embed structured transition processes aligned with hospital interface pathways and established homecare delivery models are better placed to reduce readmission risk.
This article examines how domiciliary care providers actively reduce readmissions through operational practice, governance mechanisms and alignment with commissioner and regulatory expectations.
Why Readmissions Occur at the Hospital–Home Interface
Readmissions frequently arise from missed visits, inadequate medication reconciliation, poorly communicated risks or unrealistic care planning. Discharge decisions may prioritise bed flow without fully testing whether homecare provision can safely meet needs from the first visit.
Operational Example 1: First-72-Hours Risk Model
A domiciliary care provider implemented an enhanced first-72-hours discharge model for all hospital referrals. This included mandatory double-up visits, welfare checks within four hours of discharge and senior review of care plans after day two.
Day-to-day delivery involved rota prioritisation, escalation routes for emerging risks and immediate feedback loops with hospital discharge teams. Effectiveness was evidenced through a measurable reduction in readmissions within seven days and improved commissioner confidence.
Operational Example 2: Medication Reconciliation at Discharge
Another provider embedded medication reconciliation as a mandatory discharge step. Care coordinators verified discharge summaries, reconciled MAR charts and escalated discrepancies to pharmacy teams before first administration.
Staff were trained to recognise common discharge medication risks, with competency checks completed pre-start. Evidence included reduced medication incidents and positive CQC inspection feedback.
Operational Example 3: Post-Discharge MDT Reviews
For complex discharges, a provider introduced weekly MDT reviews involving nursing, social work and therapy input. Care plans were adjusted rapidly where risks emerged.
Effectiveness was demonstrated through improved outcomes tracking, fewer emergency escalations and sustained package stability.
Commissioner Expectation: Reducing Avoidable Readmissions
Commissioners expect providers to actively support readmission reduction through robust transition management. Evidence is required through outcome data, incident analysis and clear escalation pathways.
Regulator Expectation (CQC): Safe and Responsive Care
CQC expects providers to demonstrate that risks identified at discharge are managed effectively in the community. Inspectors focus on first-visit quality, staff competence and continuity of care.
Governance and Assurance
Effective providers track readmissions as a quality indicator, linking learning to training, supervision and pathway redesign. Governance frameworks must demonstrate continuous improvement.
Outcomes and Impact
Reducing readmissions improves service user experience, protects system capacity and strengthens provider credibility. Providers able to evidence this are increasingly favoured in commissioning decisions.