Reducing Hospital Readmissions through Enhanced Transitional Care

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Reducing Hospital Readmissions through Enhanced Transitional Care and Follow-up Support

Abstract

Hospital readmissions represent a persistent challenge for health systems worldwide, particularly in the United Kingdom where the NHS continues to face pressures from growing demand, limited resources, and an ageing population. Preventable readmissions not only impose financial costs but also reduce patient confidence and negatively affect quality of care. This report explores the issue of readmissions and proposes a change strategy focused on enhanced transitional care and structured follow-up support. Using a review of literature and policy documents, it considers the effectiveness of patient education, multidisciplinary discharge planning, and digital health interventions. A cost–benefit analysis suggests that investments in these strategies can reduce long-term expenditure while improving patient satisfaction and outcomes. Kotter’s Eight-Step Change Model is applied to structure the implementation, with emphasis on building urgency, engaging staff, and embedding new practices into organisational culture. The report concludes by recommending a coordinated approach that prioritises communication, patient empowerment, and use of technology to reduce readmissions and strengthen continuity of care.

Introduction

Reducing hospital readmissions has become a central concern for healthcare systems globally, and particularly within the NHS. Readmissions are often viewed as a key quality indicator: high rates may suggest poor discharge planning, inadequate community support, or failures in patient education. While some readmissions are clinically necessary, many are considered preventable through more effective transitional care. In the United Kingdom, the National Audit Office (NAO) and NHS England have highlighted the urgent need to address the cycle of readmission, which places additional strain on already stretched resources. The NHS Long Term Plan (2019) specifically calls for stronger out-of-hospital support and better integration between primary, community, and acute care services.

The problem is magnified by demographic shifts. The UK population is ageing, with a growing prevalence of chronic diseases such as heart failure, COPD, and diabetes. These conditions are strongly associated with repeat hospital admissions. In addition, social determinants such as poor housing, limited access to social care, and low health literacy further increase the risk of readmission. Evidence indicates that nearly 20% of patients discharged from hospital are readmitted within 30 days, with significant cost implications for the NHS (King’s Fund, 2020).

This report proposes a structured organisational change project focusing on enhanced transitional care and systematic follow-up support. Transitional care refers to the coordination of healthcare during the movement of patients between different levels or settings, such as hospital to home or community. Poorly managed transitions can lead to medication errors, lack of follow-up appointments, and inadequate patient understanding of their care plan. Strengthening this process offers an opportunity to reduce avoidable readmissions, improve patient wellbeing, and increase efficiency in service delivery.

The rationale for this change lies in both patient and organisational outcomes. For patients, avoiding unnecessary readmissions means improved recovery, reduced disruption to family life, and greater confidence in managing long-term conditions. For the NHS, reduced readmission rates translate into cost savings, reduced pressure on hospital capacity, and better allocation of staff and resources. These outcomes are consistent with broader policy goals of integrated, patient-centred care.

To guide this change, the report adopts Kotter’s Eight-Step Change Model, a widely recognised framework for implementing large-scale organisational change. The model is particularly suitable in healthcare settings because it emphasises communication, stakeholder engagement, and cultural embedding. Applying this model will allow the NHS or any healthcare provider to approach readmission reduction systematically, ensuring that improvements are sustained rather than short-lived.

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