الفهرس 
Literature ReviewOnly 14 pages are availabe for public view
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Abstract
Introduction:
Every patient leaving hospital should have a system in place for post discharge follow up. Unsafe conditions in the home can lead to unnecessary or avoidable hospital readmission. Home Health Care (HHC) in Prince Sultan Military Medical City (PSMMC) is a crucial component on serving to ensure continuity of care and reduce readmissions during the first 30-days post discharge from the hospital.
Objectives: This study aimed to measure PSMMC readmission rate among patient discharged to HHC division; and to compare it with readmission rate among patient discharged to their home; also; to identify factors affecting readmission at PSMMC after discharge to HHC division.
Methodology:
Retrospective Cohort study design was conducted to study all discharged patient from PSMMC with the top three diseases (cardiovascular, Dementia and diabetes) and were followed for 30 days to measure the readmission rate among patient discharged to their home and those patient discharged to HHC division and a sample size of 414 patient was selected to study the related factors affecting the readmission rate.
Results:
Home health care patient visits were associated with a significant reduction in PSMMC readmission rate by 50%. The most important related factors were developing multidisciplinary care plan, educating patient\ caregiver. There was no multidisciplinary patient care plan for (82.1%) of the patients discharged to HHC and readmitted to hospital, compared to (9.1%) of those who were not readmitted, (P>0.001). Regarding the other group who were discharged to their houses, there was no multidisciplinary patient care plan for (78.6%) of the patient discharged to patient house and readmitted compared to (15.9%) of the patient who were not readmitted, (P>0.001). Educating patients/care giver about diagnosis, care plan, medication plan and discharge plan was significant protective action against readmission in both groups of patients discharged to HHC or to their houses.
Conclusion:
Home healthcare visits significantly reduce the PSMMC readmission rate by 50% with clear important factors that directly affect the rate which was mainly related to development of multidisciplinary care plan and educate the patient about this plan. Recommendation: Planned and scheduled home visits according to patient need through multidisciplinary HHC team play an important role in reduction of the hospital readmission rate.
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