Towards reduction of preventable hospital readmission: Older people and family members' views on planned self-management of care at home

Lindy King, Ann Harrington, Seth Nicholls, Karleen Thornton, Elizabeth Tanner

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


Aims and objectives: To reduce the likelihood of preventable readmissions, the aim was to investigate how older people (with their family members) managed their chronic health conditions at home following hospital discharge. The objectives explored older people and their family members' perspectives on how discharge plans assisted self-management of their chronic conditions, their recognition of deterioration and when to seek treatment/re-attend hospital.

Background: Chronic conditions have challenged older adults' self-management, particularly after hospital discharge and can impact on preventable readmission. Few studies have examined patients' and their family members' perspectives on the management of their conditions at home after hospitalisation.

Design: A qualitative exploratory design known as Interpretive Description was utilised.

Methods: Purposeful sampling involved 27 community-dwelling older adults; nineteen were discharged patients with one or more chronic health conditions. Eight nominated family members were also recruited to enhance understanding of the older persons' self-management at home. Interviews were undertaken and thematic data analysis followed the COREQ guidelines.

Results: Five themes emerged: (1) Post-Discharge Advice; (2) Managing at Home; (3) Recognition and Response to Deterioration; (4) Community Care and Support; and (5) The “Burden” on Others of Post-Discharge Care.

Conclusion: Older people sought a clear plan for self-management at home prior to discharge. This plan should contain potential signs of deterioration and guidance on future action. We found that support given to older people from family and friends was critical to prevent readmission. In addition, their local General Practitioner and Pharmacist played an essential part in the support of their care. For some, social support services were also important. Nurse telephone follow-up in the week following discharge was mostly absent. However, this strategy would be strongly recommended.

Relevance to clinical practice: To mitigate against preventable readmission, we recommend the above strategies to assist the older person at home with self-management of their chronic conditions.

Original languageEnglish
Pages (from-to)4599-4613
Number of pages15
JournalJournal of Clinical Nursing
Issue number15-16
Early online date16 Aug 2022
Publication statusPublished - Aug 2023


  • chronic health conditions
  • discharge home from hospital
  • family
  • nurse follow-up
  • older adults
  • post-discharge plan
  • preventable readmission
  • self-management


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