After Hospital Care Plan (AHCP) in medical patients using the Plan-Do-Study-Act (PDSA) model

Hospital readmissions remain a major challenge globally, particularly among patients with chronic illnesses. Many readmissions are preventable and linked to inadequate discharge planning, poor communication, and lack of structured follow-up. The immediate post-discharge period is a high-risk phase, with nearly one in five patients experiencing adverse events. At Aga Khan University Hospital, no formal system existed to contact patients within 48 h of discharge. This study aimed to develop and pilot an After Hospital Care Plan (AHCP) to improve post-discharge care and increase patient support. This report describes the first cycle of an ongoing quality improvement project that used the Plan–Do–Study–Act (PDSA) model to design and implement the AHCP in the Department of Medicine. The pilot was conducted during March 2024. Patients discharged from medical services were eligible for 48-hour nurse-led telephone follow-up. The intervention, based on the Re-Engineered Discharge (RED) framework, included structured nurse navigator-led telephone follow-up within 48 h of discharge. Key components included symptom assessment, medication review, appointment clarification, and triage using a standardized symptom dictionary. No comparator group was included in this initial pilot cycle. During the pilot, 1,291 patients were discharged, and 450 calls were attempted; 379 (29.3%) were successfully completed and analyzed. Among the patients contacted, 92.6% were stable, 1.8% had high-alert symptoms, and 5.5% had low-alert symptoms. The After Hospital Care Plan (AHCP) demonstrated that structured nurse-led follow-up calls within 48 h of discharge were operationally feasible, and the pilot successfully evaluated symptom triage as a process measure. This pilot identified important operational challenges that will inform subsequent PDSA cycles. No outcome evaluation was conducted, and effectiveness on patient outcomes cannot be inferred from this single PDSA cycle.