J Med Internet Res. 2026 Mar 17;28:e80529. doi: 10.2196/80529.
ABSTRACT
BACKGROUND: Unplanned emergency department (ED) visits and hospital readmissions following discharge contribute to patient distress, increased health care costs, and system inefficiencies. Early postdischarge follow-up can improve care transitions, yet evidence on the effectiveness of telephone-based interventions remains mixed. Telephone calls, a low-barrier form of digital health, may enhance equity and accessibility by reaching patients who face challenges with in-person or higher-technology follow-up.
OBJECTIVE: This study evaluated the impact of a nurse-led postdischarge telephone intervention delivered by Fraser Health Virtual Care on short-term ED visits and hospital readmissions among recently discharged high-risk patients. Secondary objectives included examining patient experiences with the service and identifying care gaps addressed during follow-up calls.
METHODS: A pragmatic quasi-randomized trial was conducted (May 2022-September 2022). Participants were eligible if they were aged 18 years or older and classified as high-risk for readmission using the LACE (Length of stay, Acuity of admission, Comorbidities, and Emergency department use) index (≥10 or <9 and ≥45 y). Participants were allocated to either a postdischarge telephone intervention group or a standard care control group based on daily nurse availability. Intervention participants received a structured nurse-led call 48 hours after discharge assessing understanding of discharge instructions, medication management, follow-up appointments, and home supports. Primary outcomes were ED visits within 7 and 30 days post call; secondary outcomes were hospital readmissions and patient experience. Negative binomial regression models were used to calculate adjusted incident rate ratios (IRRs).
RESULTS: A total of 7091 participants were included (intervention: n=3911, of whom 1752 completed the call; control: n=3180). Postdischarge calls significantly reduced ED visits at both 7 days (adjusted IRR 0.719, 95% CI 0.617-0.837; P<.001) and 30 days (IRR 0.878, 95% CI 0.783-0.983; P=.02). No statistically significant reductions were observed in hospital readmissions at either 7 days (IRR 0.809; P=.13) or 30 days (IRR 0.942; P=.54). Forty percent of completed calls (n=701) identified at least 1 gap in discharge understanding or follow-up care. Most participants found the calls helpful and reported increased confidence in managing their care.
CONCLUSIONS: Structured nurse-led postdischarge telephone calls significantly reduced short-term ED utilization but did not impact readmission rates. These findings support the role of telephone-based virtual care as a scalable, low-barrier strategy to improve care transitions and reduce avoidable ED visits. Additional or ongoing interventions may be required to influence hospital readmission outcomes among high-risk patients.
PMID:41843752 | DOI:10.2196/80529
