Implementation of discharge management for geriatric patients at risk of readmission or institutionalization

Els Steeman, Philip Moons, Koen Milisen, Nele De Bal, Sabina De Geest, Cécile De Froidmont, Véronique Tellier, Christiane Gosset, Ivo Abraham

Research output: Contribution to journalArticlepeer-review

33 Scopus citations


Objective. To evaluate whether implementation of discharge management by trained social workers or nurses reduces hospital readmissions and institutionalizations of geriatric patients in a real-world setting. De sign. Quasi-experimental design. Setting. Six general hospitals in Belgium. Participants. A representative sample of 824 patients, 355 of whom were assigned to the experimental group receiving comprehensive discharge management and 469 to the control group receiving usual care. Inclusion criteria were patients admitted to a geriatric, rehabilitation, or internal medicine ward, not residing in a nursing home, and showing risk of readmission or institutionalization on admission in the hospital. Intervention. In-hospital discharge planning according to a case management protocol allowing for adjustment to participating hospitals' case mix and patients' and families' specific needs. Main outcome measures. Hospital readmission within 15 and 90 days post discharge; institutionalization at discharge and within 15 and 90 days post discharge. Results. Discharge management resulted in fewer institutionalizations (n = 53; 14.9%) compared with usual care (n = 130; 23.7%) (adjusted odds ratio = 0.47; CI 95% = 0.31-0.70). Readmission rates between the intervention and usual care group were not significantly different. Conclusions. This implementation project showed that a discharge planning intervention can reduce institutionalization rates of elderly patients in real-life settings.

Original languageEnglish (US)
Pages (from-to)352-358
Number of pages7
JournalInternational Journal for Quality in Health Care
Issue number5
StatePublished - Oct 2006
Externally publishedYes


  • Case management
  • Elderly
  • Geriatric nursing
  • Patient discharge

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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