Unplanned Readmissions

Project Title

Patient Centred Care to Reduce Unplanned Readmission Within 28 Days.

Lead Local Health District 

Southern NSW.

Research Project


Unplanned readmission within 28 days of discharge reflects a breakdown in the continuum of care. Unplanned readmission from patients’ perspective is poorly understood. This study was conducted to understand contributors for readmission from the patient’s viewpoint.


A concurrent mixed method study was conducted using a structured telephone interview template.


Statistical analysis was conducted comparing 50 readmitted with 64 non-readmitted patients who were matched on key characteristics. Readmitted patients had a longer stay (2.2 days vs 0.55 days, p = 0.002), less knowledge of what signs or symptoms of deterioration to watch out for post discharge (p= 0.037), more difficulties getting to appointments (p= 0.046), have a care navigator (p= 0.01) and experience negative emotions on initial discharge (p=0.048).

Qualitative themes included a) communication, b) patient comfort and dignity, c) discharge issues, d) medications and e) systems issues. More than 1/3 (37%) of participants required telephone intervention at the time of data collection.

  1. Update patients contact details on all admissions
  2. Discharge information to be concise, specific and easily understood
  3. Post discharge phone calls for all patients within 3 days of discharge
  4. HealthDirect phone numbers for all patients on discharge
  5. Mental Health Access Line accessible.
Project Team Contacts
  • Dot Hughes – Dot.hughes@health.nsw.gov.au
  • Anka Radmanovich
  • Uta Conway
  • David Schmidt.