Document Type

DNP - Open Access

Award Date


Degree Name

Doctor of Nursing Practice (DNP)


Graduate Nursing

First Advisor

Robin Arends


Post-discharge telephone follow-up, causes of 30-day hospital readmissions, most-common causes of hospital readmissions, implementation, and adaptation of Reengineered Discharge (RED) toolkit


Introduction: The rate at which patients get readmitted to any hospital within 30-days of their initial admission is known as the 30-day hospital readmission rate. These readmission rates are costly but can be prevented. The two common causes for hospital readmissions include lack of understanding regarding patient medications and postdischarge follow-up with the provider. Post-discharge follow-up calls help to clear these misunderstandings and is beneficial in reducing readmission rates.
Methods: The literature search was conducted through the website of NIH National Library of Medicine, PubMed database and Google Scholar search using the keywords listed below. The review of 36 peer-reviewed, evidence-based articles that met the inclusion criteria was completed.
Gaps: There was a gap in the evidence as to what makes an effective telephone follow-up program. Literature gap exists on who is the ideal person to make the call, the frequency, timing, and the content of the calls. There were limited studies to derive conclusions considering multiple diagnoses of patients and multi-factored outcomes. Recommendations for Practice: Several studies recommended post-discharge telephone follow-up calls in reducing 30-day hospital readmissions.

Library of Congress Subject Headings

Hospitals -- Admission and discharge.
Hospitals -- After care.
Patients -- Services for.

Number of Pages



South Dakota State University


Copyright © 2021 The Author