Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle.

Rationale: Care coordination has shown inconsistent results as a mechanism to reduce hospital readmission and postdischarge emergency department (ED) visit rates.

Objective: To assess the impact of a supplemental care bundle targeting high-risk elderly inpatients implemented by hospital-based staff compared to usual care on a composite outcome of hospital readmission and/or ED visitation at 30 and 60 days following discharge.

Patients/methods: Randomized controlled pilot study in 41 medical inpatients predisposed to unplanned readmission or postdischarge ED visitation, conducted at Baylor University Medical Center.