Avoidable hospital readmissions and primary care: Interventions for older adults

Introduction: Improving hospital-to-home care transitions is a major challenge in the context of population aging. However, few studies in France describe the specific nursing interventions delivered in primary care after hospital discharge. This study examines the follow-up and support interventions provided by nurses in primary care to adults aged 75 and older within 30 days of hospital discharge, and identifies factors that facilitate or hinder their implementation.

Method: A descriptive qualitative study was conducted with eight nurses providing home-based care. Data were collected through semi-structured interviews. Thematic analysis was performed, and the findings were examined in relation to the components of the transitional care model (TCM). Results: Nurses implemented interventions consistent with the TCM (clinical assessment, coordination, caregiver involvement), as well as actions specific to the French context (technical care, prescription management, care network referrals). Their interventions were influenced by various facilitators (professional commitment, local integration, early intervention) and barriers (fragmented organization, poor communication, limited resources). Discussion: The findings support the development of an integrated nursing model inspired by the TCM and adapted to the French health care context. Further research is needed to evaluate the potential impact of such a model on care trajectories and patient outcomes.