Hospital@Home: improving discharge management and reducing the risk of rehospitalizations in multimorbid Patients – Protocol for a randomized clinical trial

Hospital rehospitalizations within 30 days represent a burden for patients and the healthcare system. Improving the care during the hospital discharge period could decrease the risk of avoidable rehospitalizations. To describe the methods of our trial aiming to define the efficacy of a tailored transition program in patients with high risk for rehospitalization compared to the usual discharge procedure with the endpoint of 30 day rehospitalization rate. Pragmatic, randomized, open-label, single-center superiority trial with a follow-up of 30 days. Included are adult patients hospitalized in an acute internal medicine department who are planned to be discharged home with a high estimated risk (20% or more) of 30-day rehospitalization. Patients in the intervention group will receive individualized and coordinated discharge management by an interdisciplinary team, compared to usual care in the control group. The multimodal intervention includes individualized pre-discharge, bridging, and post-discharge intervention components. Before enrolling the first patient, the trial was prospectively registered at the ISRCTN registry (registration date April 4th 2023) under the number ISRCTN11162162 and was approved by the ethical committee (Ethikkommission Nordwest- und Zentralschweiz (EKNZ), ID 2022–01040). This trial aims to assess the efficacy of a well-defined multicomponent discharge intervention to reduce unplanned rehospitalization rates in high-risk patients.