{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T13:51:08Z","timestamp":1790949068142,"version":"4.1.0"},"reference-count":49,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T00:00:00Z","timestamp":1774224000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Thirty-day hospital readmissions are a major clinical and economic challenge, particularly among frail older patients. Integrated protected discharge models, coordinated by nurse case managers and including multidimensional hospital-to-community interventions, may improve continuity of care and reduce inappropriate readmissions. Materials and Methods: We conducted a retrospective observational study on 200 consecutive patients aged \u226565 years, discharged between January and December 2024 from a public hospital in Italy. Frailty was assessed using BRASS scores (\u226511), ADL, and IADL. The primary outcome was 30-day hospital readmission. Logistic regression models evaluated the impact of individual interventions (Model 1) and combined interventions (Model 2), defined as the simultaneous presence of four components: nurse case manager involvement, telephone follow-up, activation of home care (ADI) within 24 h, and social worker support. Results: Overall, 65 patients (32.5%) were readmitted within 30 days. In the multivariate analysis, nurse case manager involvement was associated with lower odds of readmission (OR = 0.023; 95% CI 0.008\u20130.064; p &lt; 0.001). Early ADI activation was not associated with readmission in the bivariate analysis (p = 0.195) but showed higher odds of readmission in the multivariable model (OR = 3.475; 95% CI 1.384\u20138.725; p = 0.008). The combined interventions variable was significantly associated with readmission in Model 2. Patients who did not receive combined interventions had higher odds of 30-day hospital readmission compared with those who did (OR = 26.1; 95% CI 10.1\u201367.5; p &lt; 0.001). Conclusions: An integrated protected discharge model coordinated by a nurse case manager and including combined interventions was associated with lower odds of 30-day hospital readmission among frail older patients. These findings suggest that the potential benefit of transitional care may lie not in isolated interventions but in the multidimensional integration and coordination of clinical, functional, and social support strategies, highlighting the central role of nurse case managers in transitional care pathways.<\/jats:p>","DOI":"10.3390\/medicina62030602","type":"journal-article","created":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T13:07:06Z","timestamp":1774271226000},"page":"602","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Impact of Combined Interventions and Early Home Care Activation on 30-Day Hospital Readmissions: A Retrospective Observational Study"],"prefix":"10.3390","volume":"62","author":[{"given":"Gianluca","family":"Azzellino","sequence":"first","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"U.O.C. Adriatic District Area, Azienda Unit\u00e0 Sanitaria Locale 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-9049-8467","authenticated-orcid":false,"given":"Patrizia","family":"Vagnarelli","sequence":"additional","affiliation":[{"name":"U.O.C. Adriatic District Area, Azienda Unit\u00e0 Sanitaria Locale 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0452-3282","authenticated-orcid":false,"given":"Ernesto","family":"Aitella","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, Azienda Unit\u00e0 Sanitaria Locale 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7107-4897","authenticated-orcid":false,"given":"Francesca","family":"Cerratti","sequence":"additional","affiliation":[{"name":"Department of Medicine and Science of Aging, \u201cG. D\u2019Annunzio\u201d University of Chieti, 66100 Chieti, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-4919-8756","authenticated-orcid":false,"given":"Luca","family":"Mengoli","sequence":"additional","affiliation":[{"name":"Long-Term Care Unit, \u201cMaria SS. dello Splendore\u201d Hospital, AUSL 04 Teramo, 64021 Giulianova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1841-2807","authenticated-orcid":false,"given":"Lia","family":"Ginaldi","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, Azienda Unit\u00e0 Sanitaria Locale 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4253-1312","authenticated-orcid":false,"given":"Massimo","family":"De Martinis","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Long-Term Care Unit, \u201cMaria SS. dello Splendore\u201d Hospital, AUSL 04 Teramo, 64021 Giulianova, Italy"},{"name":"UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1542\/hpeds.2017-0031","article-title":"Provider perspectives of high-quality pediatric hospital-To-home transitions for children and youth with chronic disease","volume":"7","author":"Foster","year":"2017","journal-title":"Hosp. 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