Treated and discharged: How to avoid repeat hospital visits

The Bottom Line

  • A hospital visit is not necessarily a “once and done” event. Some patients, including older adults and those with certain chronic conditions, become frequent emergency room visitors.
  • Knowing risk of readmission and having a thorough discharge care plan gives patients and their caregivers the necessary information and instructions for effective post-treatment care.
  • Once back at home, enlisting home and community supports and making healthy life-style changes will help improve the chances of avoiding a repeat hospital visit.

After returning home from a fabulous vacation or an enjoyable visit with family or friends, you might be keen to go back again. You may even begin making plans for a future trip. Not so when it comes to a hospital stay: whether it was a scheduled surgery or a sudden health scare that took you there, once you’ve been treated and are cleared to leave you’re not planning to come back anytime soon! Yet many do, and often (1).

Frequent use of emergency department and other hospital services has major implications for healthcare systems but also for the patients who tend to have ongoing health problems and a lower life expectancy (2). Since many repeat hospital visits are due to fear, compounded by uncertainty about what to do and expect after going home (3) it’s essential that patients receive clear instructions and have access to the appropriate follow-up care.

Want to avoid repeat trips to the hospital? The following evidence-based tips are a great starting point. Click on the links for details about the related studies.

1.  Predict your risk

In Canada, nearly one in ten acute-care patients return to the emergency department after leaving the hospital (4). Some people – including older adults– are more likely to be among that 10% (5). Your age, medical condition, chronic diseases and other factors can put you at higher risk and in need of extra support and strategies for staying well while staying away from the hospital.

Research evidence shows that tools such as the Identification of Seniors At Risk (ISAR) and Probability of Repeated Admission (Pra) can help predict when you’re ready to go home from the hospital and if you’re at high risk of returning (6;7). While these tools are intended for health care professionals, you can advocate for your own care by asking about your risk and what it means for your discharge and care needs.

2.  Make a care plan

A comprehensive, tailored care plan – based on your health history and unique circumstances – is an important step towards a successful recovery and reduces the risk of suffering complications that could send you back to hospital. Discharge care plans include clearly outlined steps to follow once you leave the hospital and are an effective way to avoid going back (8). In some cases the plan will involve “case management” in which members of multidisciplinary teams (doctors, nurses, psychologists, social workers etc.) play a role in developing and carrying out the care plan. Don’t leave the hospital without asking your healthcare providers about developing an appropriate discharge plan that will meet your unique needs.

3.  Recruit your pharmacist

Older adults and others who take multiple medications are at risk of serious side effects due to drug interactions, which can result in a trip to the hospital. It’s a good idea to get a pharmacist involved even before leaving the hospital to conduct a medication review and give you instructions about your prescriptions, including the correct timing and dosage (9). Once at home, keep your pharmacist in the loop by keeping track of any medications you’re taking and how often, asking for advice and pamphlets about your prescriptions, and enlisting their help to dispose of any unused or expired medications.

4.  Access post-treatment care

Sometimes recovery includes follow-up care delivered by medical professionals. But that doesn’t always have to be in a hospital setting. Home visiting programs and transitional care or nurse-led clinics are effective options for people recovering from heart failure and with other conditions (10-13). For people living in areas without specialty clinics or services, support by telephone can work well to check on your condition and you help manage symptoms and recovery.

5.   Commit to making lifestyle changes

Often, an unplanned hospital visit is a “wake-up call” for people whose diagnosis was complicated by poor diet, lack of exercise, smoking, substance use or a combination of life-style factors. It’s never too late to make changes that will improve your health and your life – and keep you away from the emergency room. Read more in these blog posts:

–   Living with heart failure: Effective self-care is key to coping well
–   Diet or exercise: Which works best for weight loss?
–   5 diet changes supported by research evidence
–   Exercise for people with heart disease: Can health education help change behaviours?
–   5 tips to help you quit smoking for good
–   Sitting too much? Take steps to support healthy aging

Don’t go until you know

If you have to spend time in the hospital, ideally it’s a short stay involving a successful and effective treatment. You may be eager to get back home, but before you’re discharged, make sure you have the information you need and fully understand all the components of your care plan. By preventing a repeat visit to the hospital you’ll have the time and energy to plan more enjoyable trips for when you’re fully recovered!

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  1. LaCalle E, Rabin E. Frequent users of emergency departments: The myths, the data and the policy implications. Ann Emerg Med. 2010; 56(1):42-48. doi: 10.1016/j.annemergmed.2010.01.032.
  2. Moe J, Kirkland S, Ospina M et al. Mortality, admission rates and outpatient use among frequent users of emergency departments: A systematic review. Emerg Med J. 2016; 33(3):230-236. doi: 10.1136/emermed-2014-204496.
  3. Rising KL, Padrez KA, O’Brien M et al. Return visits to the emergency department: The patient perspective. Ann Emerg Med. 2015; 65(4):377-386.e3. doi: 10.1016/j.annemergmed.2014.07.015.
  4. Canadian Institute for Health Information. All-cause readmission to acute care and return to the emergency department. [Internet] 2012. [cited July 2017]. Available from
  5. Samaras N, Chevalley T, Samaras D et al. Older patients in the emergency department: A review. Ann Emerg Med. 2010; 56(3):261-269. doi: 10.1016/j.annemergmed.2010.04.015.
  6. Galvin R, Gilleit Y, Wallace E, et al. Adverse outcomes in older adults attending emergency departments: A systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age Ageing. 2017; 46(2):179-186. doi: 10.1093/ageing/afw233.
  7. Wallace E, Hinchey T, Dimitrov BD, et al. A systematic review of the probability of repeated admission score in community-dwelling adults. J Am Geriatr Soc. 2013; 61(3):357-364.
  8. Ospina MB, Mrklas K, Deuchar L, et al. A systematic review of the effectiveness of discharge care bundles for patients with COPD. Thorax. 2017; 72(1):31-39. doi: 10.1136/thoraxjnl-2016-208820.
  9. Thomas R, Huntley AL, Mann M, et al. Pharmacist-led interventions to reduce unplanned admissions for older people: A systematic review and meta-analysis of randomised controlled trials. Age Aging. 2014; 43(2):174-187. doi: 10.1093/ageing/aft169.
  10. Al-Mallah MH, Farah I, Al Madani W et al. The impact of nurse-led clinics on the mortality and morbidity of patients with cardiovascular diseases: A systematic review and meta-analysis. J Cardiovasc Nurs. 2015 
  11. Varney J, Weiland TJ, & Jelinek G. Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review. Int J Evid Based Healthc. 2014; 12(2):128-141.
  12. Feltner C, Jones CD, Cené CW et al. Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Ann Intern Med. 2014; 160(11):774-784.
  13. Weeks LE, Macdonald M, Martin-Misener R, et al. The impact of transitional care programs on health services utilization in community-dwelling older adults: A systematic review. JBI Database System Rev Implement Rep. 2018; 16(2): 345-384. doi: 10.11124/JBISRIR-2017-003486. 

DISCLAIMER: These summaries are provided for informational purposes only. They are not a substitute for advice from your own health care professional. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the McMaster Optimal Aging Portal (

Many of our Blog Posts were written before the COVID-19 pandemic and thus do not necessarily reflect the latest public health recommendations. While the content of new and old blogs identify activities that support optimal aging, it is important to defer to the most current public health recommendations. Some of the activities suggested within these blogs may need to be modified or avoided altogether to comply with changing public health recommendations. To view the latest updates from the Public Health Agency of Canada, please visit their website.