European Geriatric Medicine (2018) 9:329–337
Early geriatric follow‑up visits to nursing home residents reduce
the number of readmissions: a quasi‑randomised controlled trial
Lene Holst Pedersen
· Merete Gregersen
· Ishay Barat
· Else Marie Damsgaard
Received: 10 January 2018 / Accepted: 13 March 2018 / Published online: 9 April 2018
© European Geriatric Medicine Society 2018
Introduction Nursing home residents have a high risk of being readmitted after hospitalisation. The objective of this study is
to test whether an early geriatric follow-up visit can reduce readmissions among nursing home residents without increasing
mortality. The main components of the intervention will also be quantiﬁed.
Materials and method A quasi-randomised controlled design. A population of nursing-home residents aged 75 years or older
admitted to hospital with one of nine medical diagnoses. All patients received comprehensive geriatric assessment before
discharge. The intervention comprised a visit by a nurse and a doctor from a geriatric team the ﬁrst weekday after discharge.
Control group patients were oﬀered a follow-up visit by their general practitioner 7–14 days after discharge.
Results Six hundred and forty-eight patients were included in the study between June 1st 2014 and December 15th 2016. In
the intervention group, 13% were readmitted within 30 days after discharge, compared to 19% in the control group (p = 0.04).
Adjusted hazard ratio = 0.63 (95% CI 0.42–0.95). The median length of hospital stay was 1 day for both groups. Neither
30 nor 90-day mortality were aﬀected by the intervention. The most commonly registered intervention element was direct
person-to-person contact between hospital and nursing home staﬀ or relatives, followed by changes in medication and blood
Conclusion Early geriatric follow-up visits to recently discharged nursing home residents are a safe and eﬀective way of
reducing readmissions. Communication, changes in medication, and blood tests were the most frequently performed elements.
Keywords Nursing home residents · Readmissions · Length of hospital stay · Mortality · Follow-up visit · Geriatrics
Hospital readmissions of nursing home residents are a
signiﬁcant problem, and risk factors such as comorbidity,
polypharmacy, dementia, and functional disabilities are
frequent [1–3]. International studies have shown that after
hospitalisation, both permanent and temporary nursing
home residents have a higher risk of hospital readmission
than patients living in their own home [4–8]. Thirty-day hos-
pital readmission rates are as high as 18–31% [9–11]. Both,
in-hospital- and post-hospital mortality are very high among
patients admitted from nursing homes [12–14].
Communication between hospitals and nursing homes
is essential for safe transitions. Inadequate communication
increases the risk of readmission . Emergency Depart-
ment staﬀ and nursing home staﬀ agree that inadequate
information during transition is the most frequent barrier to
high-quality care .
Various programs have been designed to enhance patient-
care communication and reduce readmissions. Interventions
combining forms, checklists, and person-to-person contact
have reduced hospital readmissions among nursing home
residents [17, 18].
Owing to an increasing shortage of hospital beds, hos-
pital admissions of nursing home residents are very brief
* Lene Holst Pedersen
Else Marie Damsgaard
Aarhus University Hospital, Palle Juul-Jensens Boulevard
99, 8200 Aarhus N, Denmark
The Regional Hospital in Horsens, Sundvej 30,
8700 Horsens, Denmark