Abstract

Hospital readmissions among chronic disease patients remain a persistent challenge, contributing to poor patient outcomes, increased healthcare costs, and strained clinical resources. Conditions such as heart failure, chronic obstructive pulmonary disease (COPD), and diabetes account for a significant proportion of preventable readmissions, highlighting the need for systematic, coordinated approaches to patient care. Current care models often suffer from fragmented practices, inconsistent communication between inpatient and outpatient teams, and inadequate post-discharge follow-up, which collectively compromise continuity of care and patient safety. In response, this paper proposes a comprehensive care-coordination framework designed to reduce readmissions by integrating policy, workflow, and interdisciplinary collaboration across the continuum of care. The framework emphasizes early risk stratification to identify high-risk patients, enabling tailored care plans that encompass evidence-based disease management, medication optimization, lifestyle interventions, and scheduled follow-up. Interoperable electronic health records (EHRs), structured communication protocols, and digital care platforms facilitate real-time information sharing, improve handoffs, and support timely interventions. Patient and caregiver engagement is central to the framework, incorporating education, self-management support, and remote monitoring tools to reinforce adherence and enable proactive response to clinical changes. Operational strategies such as staff training, multidisciplinary huddles, and continuous monitoring of key performance indicators (KPIs) ensure that the framework is consistently applied and refined based on outcomes data. By aligning institutional policies with frontline practice, promoting evidence-based interventions, and fostering collaborative care, the framework aims to enhance patient outcomes, reduce unnecessary readmissions, and optimize resource utilization. This conceptual framework provides a structured, evidence-informed approach to chronic disease management, bridging gaps between inpatient care, outpatient follow-up, and community support. It serves as a foundation for pilot studies, empirical validation, and scalability across diverse hospital settings, offering a sustainable model for improving patient safety, continuity of care, and long-term health outcomes.