Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living with Chronic Conditions

Colleen A. Pogue
Amelia E. Schlak
Matthew D. McHugh
Peer-Reviewed Article
January 2024
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Nurse assessments of discharge readiness for older patients with multiple chronic conditions (MCCs) can help identify patients at high risk for hospital readmission.


Older adults with multiple chronic conditions (MCCs) experience worse outcomes following hospital discharge, including higher risks for mortality and rehospitalization. Nurses help ensure that patients are ready for discharge by monitoring critical aspects of their experiences, including health status and presence of social risk factors, such as unstable housing.

Despite their critical role, studies have not investigated whether nurses’ assessments of discharge readiness can reliably predict hospital readmission for older adults with MCCs. This study explored if nurses’ discharge assessments of Medicare patients with MCCs in 424 hospitals across several states can help identify patients at high risk of readmission.


On average, 45% of nurses in participating hospitals were confident in their patients’ readiness for discharge. Fourteen percent of patients with five or more conditions were readmitted to a hospital within 30 days of discharge, compared to 7% of patients with two to four conditions, and 5% of patients with one condition. However, for each 10% increase of nurses who were confident in their patients’ discharge readiness, the risk for 30-day readmission reduced by 3% for patients with five or more conditions and 2% for patients with two to four conditions, compared to patients with one condition.


Medicare’s Hospital Readmissions Reduction Program (HRRP) and other value-based payment (VBP) models reduce payments to hospitals that fail to mitigate avoidable readmissions. This study suggests that hospitals that integrate nurses into their patient discharge strategies may achieve strong performance in VBP quality measures. Nurse assessments were critical in reducing the risk of readmission for patients with MCCs, suggesting that nurses can help improve post-acute care outcomes for these patients following hospitalization.

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