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Brief Assessments Before Hospital Discharge Can Reduce Readmissions

Abt’s Morris Hamilton joined a team of researchers to test whether nurses can reduce costly patient readmissions by adding a brief, structured assessment of patient readiness prior to discharge. Using a randomized clinical trial, the READI study team (Readiness Evaluation and Discharge Interventions) found that readmission rates were reduced by as much as 1.79 percentage points in high readmission settings when nurses included direct input from patients during discharge readiness assessments. The study was conducted from 2014 to 2017 and included more than 144,000 adult patients from 33 Magnet-designated hospitals.

The READI assessment tools offer a low-intensity, low-cost approach to improving the efficacy of hospital discharge. The short eight-item questionnaire completed by both discharge nurses and patients produces information that helps to identify low readiness for discharge as well as actions health care providers can take to better prepare patients for discharge. The questionnaires capture four dimensions of readiness:

  1. Personal status (physical readiness and energy),
  2. Knowledge (problems to watch for and restrictions),
  3. Perceived coping ability (handling demands at home and performing personal care) and
  4. Expected support (help with personal care and help with medical care).


Most nurses completed their questionnaire in under two minutes, and most patients completed theirs in under five minutes.

The study concluded that hospitals should consider incorporating the READI assessment tools into their discharge practices for patients going home to reduce high rates of readmissions. The results are available in the Journal of the American Medical Association’s (JAMA) Network Open.

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