A randomized trial evaluated a reengineered hospital discharge program to reduce rehospitalization and emergency department visits. The study involved 749 English-speaking hospitalized adults, with 370 in the intervention group and 368 in the usual care group. The intervention included a nurse discharge advocate and a clinical pharmacist. The nurse worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and provide patient education. The pharmacist called patients 2-4 days after discharge to reinforce the discharge plan and review medications. The intervention group had a lower rate of hospital utilization (0.314 vs. 0.451 visits per person per month) compared to the usual care group. The intervention was most effective among patients with high prior hospital utilization. The study found that the intervention reduced hospital readmissions and emergency department visits within 30 days of discharge. However, the study was conducted at a single center, and not all eligible patients could be enrolled. The results suggest that a comprehensive discharge program can reduce unnecessary hospital use. The study highlights the importance of coordinated discharge planning, patient education, and post-discharge follow-up. The intervention included a nurse discharge advocate, a comprehensive after-hospital care plan, and a post-discharge phone call by a pharmacist. The study found that the intervention reduced hospital utilization by about 30% and improved patient preparedness for discharge. The cost analysis showed that the intervention reduced overall costs by 33.9%. The study supports the implementation of a standardized discharge program to improve patient outcomes and reduce hospital utilization. The study has limitations, including a single-center design and reliance on self-reported data. The findings suggest that a systematic approach to hospital discharges can reduce unnecessary health service use.A randomized trial evaluated a reengineered hospital discharge program to reduce rehospitalization and emergency department visits. The study involved 749 English-speaking hospitalized adults, with 370 in the intervention group and 368 in the usual care group. The intervention included a nurse discharge advocate and a clinical pharmacist. The nurse worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and provide patient education. The pharmacist called patients 2-4 days after discharge to reinforce the discharge plan and review medications. The intervention group had a lower rate of hospital utilization (0.314 vs. 0.451 visits per person per month) compared to the usual care group. The intervention was most effective among patients with high prior hospital utilization. The study found that the intervention reduced hospital readmissions and emergency department visits within 30 days of discharge. However, the study was conducted at a single center, and not all eligible patients could be enrolled. The results suggest that a comprehensive discharge program can reduce unnecessary hospital use. The study highlights the importance of coordinated discharge planning, patient education, and post-discharge follow-up. The intervention included a nurse discharge advocate, a comprehensive after-hospital care plan, and a post-discharge phone call by a pharmacist. The study found that the intervention reduced hospital utilization by about 30% and improved patient preparedness for discharge. The cost analysis showed that the intervention reduced overall costs by 33.9%. The study supports the implementation of a standardized discharge program to improve patient outcomes and reduce hospital utilization. The study has limitations, including a single-center design and reliance on self-reported data. The findings suggest that a systematic approach to hospital discharges can reduce unnecessary health service use.