Comprehensive discharge follow-up in patients' homes by GPs and district nurses of elderly patients

The patients were randomized to either an intervention group receiving a structured home visit by the GP and the district nurse one week after discharge, followed by two contacts after three and eight weeks, or to a control group receiving the usual care. A total of 331 patients aged 78 years discharged from Glostrup Hospital, Denmark, were included.

Control-group patients were more likely to be readmitted than intervention-group patients (52% v 40%; p 0.03). In the intervention group, the proportions of patients who used prescribed medication of which the GP was unaware (48% vs. 34%; p 0.02) and who did not take the medication prescribed by the GP (39% vs. 28%; p 0.05) were smaller than in the control group.

The intervention shows a possible framework securing the follow-up on elderly patients after discharge by reducing the readmission risk and improving medication control.