Introduction
readmissions
ADVERSE EVENTS
Transitions between hospital and primary care settings are identified as high-risk scenarios for patient safety that often result in adverse events, such as unplanned readmissions [Transitional care interventions (TCIs) are one strategy for preventing readmissions. Transitional care is defined as ‘a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, subacute and post-acute nursing facilities, the patient’s home, primary and specialty care offices, and assisted living and long-term care facilities’ [Despite the diversity of studies, we have yet to examine the effects on readmissions among an unselected medical patient group in a regional setting where the demographics, geographical distances and healthcare services differ from large urban settings.The objective of this study was to examine the effect of a hospital-based TCI on readmissions among older medical patients admitted to a general medical ward at a regional hospital. We hypothesised that cross-sectorial collaboration with a follow-home function, post-discharge cross-sectorial video conferences and telephone consultations would reduce the number of all-cause unplanned readmissions compared to patients who received usual care without this cross-sectorial collaboration.