Fewer vulnerable patients would be re-admitted to hospital if a local nurse could help them into medical services in their own community.

A study by the Royal Australasian College of Physicians found the number of at-risk patients returning to hospital fell by 66 per cent if they had help from a professional within 30 days of being discharged.

Researchers followed 325 patients of Peninsula Health hospitals in southeast Melbourne from May to November 2017 who were identified as being at risk of coming back within weeks.

Most had complex conditions such as chronic heart or respiratory diseases, were older and more likely to live alone.

More than 260 received standard care but 63 were connected with a nurse who could help them find follow-up services, remind them of appointments, speak with their GP or help them with other matters such as transport and housing.

Those who received the extra assistance were less likely to return to hospital within a month.

The study's senior author Nadine Andrew said its preliminary findings published in the college's Internal Medicine Journal show targeted programs can ease strain on the health system.

"Better co-ordination between hospitals, patients and the community not only improve an individual's health outcomes but is likely to ease the financial burden on the healthcare system by reducing unnecessary re-admissions," she said.

"Something as simple as a phone call can make all the difference to vulnerable patients."