*Purpose: Kidney transplant recipients often experience frequent ED visits and high early hospital readmission (EHR) rates (within 30 days). We sought to decrease our preventable EHR by intensifying and standardizing our discharge handoff and post-operative follow-up. Herein we report our experience 1 year after implementation.

*Methods: We retrospectively reviewed the demographics, hospital and post-discharge course for 486 adult kidney-only transplant recipients from 2015-2018. EHR was defined as admission to an inpatient facility within 30 days of index discharge. Data were analyzed using the chi-squared or 2-tailed t-test.

*Results: The overall 30-day readmission rate was 20% (97/486). Of the 486 patients studied, significantly increased EHR rates were seen for black patients (28.7% vs 17.9% p=0.03), patients who had received prior transplants (29.9% vs 18.1%, p=0.018) and diabetics regardless of type (27.1% vs 17.4% p=0.017). No difference in EHR was seen for sex, preemptive transplant, age, BMI, or deceased versus living donor recipients. In Sept 2017, discharge follow up was standardized and intensified based on prior work characterizing the timing and etiology of EHR at our institution. Follow up now consists of warm handoff from inpatient to outpatient teams, a POD#1 phone call, and scheduling of the 1st clinic visit within 5 days and the 2nd within 10 days. Patients are seen twice per week for at least 3 weeks after discharge. Patient education was intensified in both inpatient and outpatient settings, particularly regarding medication. At 1 year since implementation, our EHR rates have significantly decreased from 23.1% (76/329) to 13.4% (21/157) p=0.012. In addition, the disparity in EHR rates between black and white patients has decreased post-implementation. Pre-intervention, the EHR rate for white patients was 20.1% (45/224) and for black patients was 32.9% (27/82) p=0.049. However, after intervention, EHR rates for white patients decreased to 13.9% (17/122) and for black patients to 15.4% (4/26) p=0.51. The main drivers of readmission have also changed since intensification of follow up with less readmission for bleeding/acute anemia (11.8% of readmissions pre, 4.8% post), metabolic & chronic anemia (14.5% pre vs. 0% post) and other medical causes (23.7% vs 19% post). Early readmissions for surgical complications, infection, cardiopulmonary events, and rejection have remained stable.

*Conclusions: Efforts to decrease early readmission were targeted at detailed patient handoff, patient education and intensified contact over the first 3 weeks post-discharge. Since implementation, we have seen an encouraging decrease in 30-day readmission rates from 23.1% to 13.4% while closing the gap between EHR rates for black and white patients. Frequent provider-initiated contact removes barriers for the patient during a complex transition and decreases unnecessary hospitalization.

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