Reducing Thirty-Day Readmissions Among Geriatric Patients Through Multidisciplinary Care: A Tertiary Center Experience

Background: Geriatric patients represent a growing proportion of the population, accounting for more than 9% globally. At our study center, admissions to general medical services comprise over 30% of geriatric patients. This study investigated the reasons for 30-day readmissions among geriatric patients and the impact of a multidisciplinary approach on reducing readmission rates. Methods: A retrospective, observational study was conducted at a tertiary care center in the Eastern Province of Saudi Arabia. Data was collected on patients aged ≥60 years admitted under the general medicine unit between October 2022 and August 2023 (October–December 2022 for baseline, and January 2023–August 2024 for action, intervention and result). Information was extracted from the hospital’s health informatics system (HIS), including demographics, comorbidities, reasons for readmission, post-discharge care, and outcomes. The multidisciplinary approach included nutritional support (nutritional assessment by referral to dietitian), wound care, virtual post-discharge clinics, family meetings, home healthcare, involvement of social services and psychiatry when indicated. The 30-day readmission rate was calculated by dividing the number of geriatric patients readmitted within 30 days of their last admission by the total number of geriatric patients admitted to internal medicine each month, with a benchmark of 11–23% from previous studies. Results: Of 650 geriatric patients, N = 100 required 30-day readmission. Among those 100 geriatric patients (mean age 78), 48% were over 80 years old, 41% had dementia, and 67% were bedridden (defined as the patient’s inability to get out of bed, ambulate, or sit upright without assistance). Hypertension (90%), type 2 diabetes mellitus (78%), and renal impairment (50%) were the top comorbidities. Urinary tract infections (24%) and pneumonia (17%) were the leading causes of readmission. Post-discharge interventions included virtual clinics within 1–2 weeks (49%), home healthcare referrals (27%), and regular outpatient follow-up (87%). Despite a mortality rate of 16% during the study period, the 30-day readmission rate was reduced to less than 23% from 40% in the fourth quarter of 2022 (baseline). Conclusions: The observed reduction in 30-day readmissions coincided with multidisciplinary care, yet SPC (Statistical Process Control) analysis confirmed process stability, supporting an observational rather than causal interpretation.