Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.

Actions to reduce re-admissions can be targeted to patient groups at risk, and should be aimed at the caring for chronic cardiovascular or pulmonary diseases, preventing complications and multiple ED visits, and ensuring continuity of care after discharge, especially for patients discharged on Friday.

Introduction: The quality of transitions from the hospital to home is critical for preventing readmissions. The aims of this study were to evaluate variations in the quality of transitions across groups of patients and across hospitals with high and low readmission rates and to study the impact of transitions on postdischarge outcomes. Methods: A multicenter cohort study was conducted at 12 Flemish hospitals between June 2013 and September 2015 to examine transitions for patients with heart failure, pneumonia, or total hip/knee arthroplasty. Hospitals with high and low readmission rates were selected based on readmission rates in 2008. The quality of the transitions was assessed based on readiness for discharge, patient education, general practitioner contributions to the discharge process, and timeliness and completeness of discharge summaries. Results: A total of 233 patients were included in the study. Readiness for discharge was better in patients with total hip/ knee arthroplasty than in those with heart failure or pneumonia (mean differences 11.1 (95% CI 5.3-16.9) (p ¼ 0.001) and 5.8 (95% CI 1.2-10.5) (p ¼ 0.016), respectively). Heart failure patients had better readiness scores in low readmission rates than in high readmission rates hospitals (mean difference 13.5 (95% CI 2.5-24.5)) (p ¼ 0.017). Insufficient timeliness of discharge summaries was a risk factor for postdischarge events (OR 10.564; 95% CI 1.476-75.603; p ¼ 0.019). Discussion: To improve the quality of transitions from hospital to home, communication with general practitioner s must occur in a timely manner and with a focus on the continuity of care. Particularly, in patients with complex postdischarge needs, preparing patients for discharge is essential to prevent readmissions.

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