Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults

A scoping review of interventions for older adults transitioning from hospital to home

BACKGROUND/OBJECTIVES

Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers.

DESIGN

Scoping review.

METHODS

Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results.

RESULTS

Five hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality.

CONCLUSION

To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.

Effect of nutritional and physical exercise intervention on hospital readmission for patients aged 65 or older: a systematic review and meta-analysis of randomized controlled trials

Background

Unplanned readmission may result in consequences for both the individual and society. The transition of patients from hospital to postdischarge settings often represents a discontinuity of care and is considered crucial in the prevention of avoidable readmissions. In older patients, physical decline and malnutrition are considered risk factors for readmission. The purpose of the study was to determine the effects of nutritional and physical exercise interventions alone or in combination after hospital admission on the risk of hospital readmission among older people.

Methods

A systematic review and meta-analysis of randomized controlled studies was conducted. The search involved seven databases (Medline, AMED, the Cochrane Library, CINAHL, Embase (Ovid), Food Science Source and Web of Science) and was conducted in November 2018. An update of this search was performed in March 2020. Studies involving older adults (65 years and above) investigating the effect of nutritional and/or physical exercise interventions on hospital readmission were included.

Results

A total of 11 randomized controlled studies (five nutritional, five physical exercise and one combined intervention) were included and assessed for quality using the updated Cochrane Risk of Bias Tool. Nutritional interventions resulted in a significant reduction in readmissions (RR 0.84; 95% CI 0.70–1.00, p = 0.049), while physical exercise interventions did not reduce readmissions (RR 1.05; 95% CI 0.84–1.31, p-value = 0.662).

Conclusions

This meta-analysis suggests that nutrition support aiming to optimize energy intake according to patients’ needs may reduce the risk of being readmitted to the hospital for people aged 65 years or older.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01123-w.

Postoperative duration of opioid use and acute healthcare services use in cancer patients hospitalized for thoracic surgery

BACKGROUND

Postoperative pain control is an important cancer care component. However, opioid consumption has resulted in a surge of adverse events, with thoracic surgery patients having the highest rate of persistent use. The effect of opioid duration post-discharge and the risk of increased acute healthcare use in this population remains unclear.

METHODS

A prospective cohort of non-metastatic cancer patients was assembled from an academic health center in Montreal (Canada). Clinical data linked to administrative claims from the universal healthcare program was used to determine the association between time-varying opioid patterns and emergency department (ED) visits/re-admissions/death 3 months following thoracic surgery.

RESULTS

Of the 610 patients, 77% had at least one opioid dispensed post-discharge. Compared to non-opioid users, <15 days of use was associated with a 42% decreased risk of acute healthcare events, adjusted HR 0.58, 95% CI (0.40-0.85); longer durations were not associated with an increased risk. Compared to short-term use (<15 days), use of >30 days was associated with a 72% increased risk of the outcome, aHR: 1.72, 95% CI (1.01-2.93).

CONCLUSION

There was a variation in the risk of acute healthcare use associated with postsurgical opioid use. Findings from this study may be used to inform postoperative prescribing practices.

Geriatric co-management for cardiology patients in the hospital: A quasi-experimental study

BACKGROUND/OBJECTIVES

Older patients admitted to cardiac care units often suffer functional decline. We evaluated whether a nurse-led geriatric co-management program leads to better functional status at hospital discharge.

DESIGN

A quasi-experimental before-and-after study was performed between September 2016 and December 2018, with the main endpoint at hospital discharge and follow-up at 6 months.

SETTING

Two cardiac care units of the University Hospitals Leuven.

PARTICIPANTS

One hundred and fifty-one intervention and 158 control patients aged 75 years or older admitted for acute cardiovascular disease or transcatheter aortic valve implantation.

INTERVENTION

A nurse from the geriatrics department performed a comprehensive geriatric assessment within 24 h of admission. The cardiac care team and geriatrics nurse drafted an interdisciplinary care plan, focusing on early rehabilitation, discharge planning, promoting physical activity, and preventing geriatric syndromes. The geriatrics nurse provided daily follow-up and coached the cardiac team. A geriatrician co-managed patients with complications.

MEASUREMENTS

The primary outcome was functional status measured using the Katz Index for independence in activities of daily living (ADL; one-point difference was considered clinically relevant). Secondary outcomes included the incidence of ADL decline and complications, length of stay, unplanned readmissions, survival, and quality of life.

RESULTS

The mean age of patients was 85 years. Intervention patients had better functional status at hospital discharge (8.9, 95% CI = 8.7-9.3 versus 9.5, 95% CI = 9.2-9.9; p = 0.019) and experienced 18% less functional decline during hospitalization (25% vs. 43%, p = 0.006). The intervention group experienced significantly fewer cases of delirium and obstipation during hospitalization, and significantly fewer nosocomial infections. At 6-month follow-up, patients had significantly better functional status and quality of life. There were no differences regarding length of stay, readmissions, or survival.

CONCLUSION

This first nurse-led geriatric co-management program for frail patients on cardiac care units was not effective in improving functional status, but significantly improved secondary outcomes.

Effectiveness of nurse-led peri-discharge interventions for reducing 30-day hospital readmissions: Network meta-analysis

BACKGROUND

Existing systematic reviews have compared the effectiveness of nurse-led peri-discharge interventions comprising different components with usual care on reducing all-cause 30-day hospital readmissions. However, conflicting results were reported.

OBJECTIVE

We conducted a network meta-analysis to evaluate the comparative effectiveness of different nurse-led peri-discharge interventions, compared with usual care, for reducing all-cause 30-day hospital readmissions.

DESIGN

Network meta-analysis.

METHODS

A total of five international databases were searched for systematic reviews of randomized controlled trials. Additional searches for most updated randomized controlled trials published between 2014 to 2019 were conducted. Data from included randomized controlled trials were extracted for random-effect pairwise meta-analyses. Pooled risk ratios with 95% confidence interval were used to quantify impact of nurse-led peri-discharge interventions on all-cause 30-day hospital readmissions. Network meta-analysis was used to evaluate the comparative effectiveness of different interventions.

RESULTS

From two systematic reviews and additional randomized controlled trial searches, 12 eligible randomized controlled trials (n=150,840) assessing 15 different nurse-led peri-discharge interventions were included. For reducing all-cause 30-day hospital readmissions, pairwise meta-analysis showed that there was no significant difference between nurse-led peri-discharge interventions and usual care (pooled risk ratios = 0.86, 95% confidence interval: 0.71-1.04, moderate quality of evidence). Network meta-analysis indicated no significant difference across different interventions despite variation in complexity.

CONCLUSIONS

Our results indicated that nurse-led peri-discharge interventions were not significantly different from usual care for reducing all-cause 30-day hospital readmissions. Simpler nurse-led peri-discharge interventions are on par with more complex interventions in terms of effectiveness. Benefits of nurse-led peri-discharge interventions may vary across health system context. Therefore, careful consideration is required prior to implementation.

REGISTRATION DETAILS

The protocol for this study has been registered in PROSPERO (Registration No. CRD42020186938). Tweetable abstract: This study suggested that nurse-led peri-discharge interventions do not differ from usual care for reducing all-cause 30-day hospital readmissions.

Impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review

OBJECTIVES

To identify and synthesise available evidence on the impact of transitional care interventions with both predischarge and postdischarge elements on readmission rates in older medical patients.

DESIGN

A systematic review.

METHOD

Inclusion criteria were: medical patients ≥65 years or mean age in study population of ≥75 years; interventions were transitional care interventions between hospital and home with both predischarge and postdischarge components; outcome was hospital readmissions. Studies were excluded if they: included other patient groups than medical patients, included patients with only one diagnosis or patients with only psychiatric disorders. PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from January 2008 to August 2019. Study selection at title level was undertaken by one author; the remaining selection process, data extraction and methodological quality assessment were undertaken by two authors independently. A narrative synthesis was performed, and effect sizes were estimated.

RESULT

We identified 1951 records and included 11 studies: five randomised trials, four non-randomised controlled trials and two pre-post cohort studies. The 11 studies represent 15 different interventions and 29 outcome results measuring readmission rates within 7-182 days after discharge. Twenty-two of the 29 outcome results showed a drop in readmission rates in the intervention groups compared with the control groups. The most significant impact was seen when interventions were of high intensity, lasted at least 1 month and targeted patients at risk. The methodological quality of the included studies was generally poor.

CONCLUSION

Transitional care interventions reduce readmission rates among older medical patients although the impact varies at different times of outcome assessment. High-quality studies examining the impact of interventions are needed, preferably complimented by a process evaluation to refine and improve future interventions.

PROSPERO REGISTRATION NUMBER

CRD42019121795.

CARE TRANSTION IN HOSPITAL DISCHARGE FOR ADULT PATIENTS: INTEGRATIVE LITERATURE REVIEW

ABSTRACT Objective: to summarize and analyze the scientific production on care transition in the hospital discharge of adult patients. Method: integrative review, conducted from May to July 2020, in four relevant databases in the health area: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus and Virtual Health Library (VHL). The analysis of the results occurred descriptively and was organized into thematic categories that emerged according to the similarity of the contents extracted from the articles. Results: 46 articles from national and international journals, with a predominance of descriptive/non-experimental studies or qualitative studies, met the inclusion criteria. Five categories were identified: discharge and post-discharge process; Continuity of post-discharge care; Benefits of care transition; Role of nurses in care transition and Experiences of patients on care transition. Hospital discharge and care transitions are interconnected processes as transitions qualify the dehospitalization process. Different strategies for continuity of care should be adopted, as they offer greater safety to the patient. Studies have shown that nurses play a fundamental role in transitions and, in Brazil, this activity still needs to gain more space. Reduced hospitalizations, mortality, hospital costs and patient satisfaction are benefits of transitions. Conclusion: care transition is an effective strategy for the care provided to the patient being discharged. It points out the need for integration between the care network and assists services in decision-making about the continuity of care on discharge.

Unplanned hospitalizations in older patients with cancer: Occurrence and predictive factors

BACKGROUND

This study aims to investigate the occurrence of unplanned hospitalizations in older patients with cancer and to determine predictive factors.

METHODS

A prospective Belgian multicentre (n = 22), observational cohort study was performed. Patients ≥70 years with a malignant tumor were included. Patients underwent G8 screening followed by geriatric assessment (GA) if abnormal at baseline and were followed for unplanned hospitalizations at approximately three months. Uni- and multivariable regression models were performed to determine predictive factors associated with unplanned hospitalizations in older patients with an abnormal G8.

RESULTS

In total, 7763 patients were included in the current analysis of which 2409 (31%) patients with a normal G8 score and 5354 (69%) with an abnormal G8 score. Patients with an abnormal G8 were hospitalized more frequently than patients with a normal G8 (22.9% versus 12.4%; p < 0.0001). Reasons for unplanned hospitalizations were most frequently cancer related (25.7%) or cancer therapy related (28%). In multivariable analysis, predictive factors for unplanned hospitalizations in older patients with cancer and an abnormal G8 were female gender, absence of surgery, chemotherapy, ADL dependency, malnutrition and presence of comorbidities.

CONCLUSION

Older patients with cancer and an abnormal G8 screening present a higher risk (23%) for unplanned hospitalizations. Predictive factors for these patients were identified and include not only patient and treatment related factors but also GA related factors.

Development of an informational support questionnaire of transitional care for aged patients with chronic disease

OBJECTIVES

We developed an informational support questionnaire of transitional care (ISQTC) for aged patients with chronic disease and investigated its reliability and validity.

SETTING

This study was conducted in three large general hospitals in Nantong, Jiangsu Province, China.

PARTICIPANTS

A total of 130 aged patients with chronic diseases, admitted into outpatient and inpatient departments from three hospitals in China, participated in the study. The inclusion criteria were: (1) patients must provide consent to participate; (2) being 60 years and above; (3) being diagnosed with at least one chronic disease and hospitalised more than two times within the last 1 year; (4) being able to listen, speak, read and write. The exclusion criteria were: (1) refusing to participate; (2) language expression and communication barriers (and having no caregiver to assist in participation); (3) being in intensive care or long-term hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The developed questionnaire was validated and tested for reliability. The content validity of the questionnaire was determined through experts' interviews and Delphi expert consultation, and the structure validity of the questionnaire was determined by performing exploratory factor analysis. The coefficient of reliability of the questionnaire was measured using Cronbach's alpha.

RESULTS

Through Delphi expert consultation and exploratory factor analysis, the questionnaire was reduced from four dimensions and 12 items to three dimensions and 11 items. A total of 130 patients responded to the questionnaire. The alpha coefficient was 0.747.

CONCLUSION

The ISQTC is a reliable and valid instrument for evaluating aged patients with chronic disease in transitional care.

TRIAL REGISTRATION DETAILS

ChiCTR1900020923. The trial was registered on 22 January 2019.

Patients' perceptions of frequent hospital admissions: a qualitative interview study with older people above 65 years of age

BACKGROUND

Although 'frequent flyer' hospital admissions represent barely 3 to 8% of the total patient population in a hospital, they are responsible for a disproportionately high percentage (12 to 28%) of all admissions. Moreover, hospital admissions are an important contributor to health care costs and overpopulation in various hospitals. The aim of this research is to obtain a deeper insight into the phenomenon of frequent flyer hospital admissions. Our objectives were to understand the patients' perspectives on the cause of their frequent hospital admissions and to identify the perceived consequences of the frequent flyer status.

METHODS

This qualitative study took place at the University Hospital of Leuven. The COREQ guidelines were followed to provide rigor to the study. Patients were included when they had at least four overnight admissions in the past 12 months, an age above 65 years and hospital admission at the time of the study. Data were collected via semi-structured interviews and encoded in NVivo.

RESULTS

Thirteen interviews were collected. A total of 17 perceived causes for frequent hospital admission were identified, which could be divided into the following six themes: patient, drugs, primary care, secondary care, home and family. Most of the causes were preventable or modifiable. The perceived consequences of being a frequent flyer were divided into the following six themes: body, daily life functioning, social participation, mental status and spiritual dimension. Negative experiences were linked to frequent flying and could be situated mainly in the categories of social participation, mental status and spiritual dimensions.

CONCLUSIONS

Frequent hospital admissions may be conceived as an indicator, i.e., a 'red flag', of patients' situations characterized by physical, mental, spiritual and social deprivation in their home situation.

Emergency department visits and hospital readmissions in an Argentine health system

BACKGROUND AND GOAL OF STUDY

The scope of health in the Sustainable Development Goals is much broader than the Millennium Development Goals, spanning functions such as health-system access and quality of care. Hospital readmission rate and ED-visits within 30 days from discharge are considered low-cost quality indicators. This work assesses an indicator of quality of care in a tertiary referral hospital in Argentina, using data available from clinical records.

PURPOSE

To estimate the rate of ED-visits and the hospital readmission rate (HRR) after a first hospitalization (First-H), and to identify associated factors.

METHODS

This retrospective cohort included patients who had a First-H in Hospital Italiano de Buenos Aires between 2014-2015. Follow-up occurred from discharge until ED-visit, readmission, death, disaffiliation from health insurance, or 13 months. We present HRR at 30 days and ED-visits rate at 72 h, using the Cox proportional-hazards regression model to explore associated factors, and reporting adjusted hazard ratios (HR) with their respective 95 %CI.

RESULTS

The study comprised 10,598 hospitalizations (median age was 68 years). Of these, 5966 had at least one consultation to the ED during follow up, resulting in a 24 h rate of consultations to ED of 1.51 % (95 %CI 1.29-1.72); at 48 h 3.18 % (95 %CI 2.86-3.54); at 72 h 4.71 % (95 %CI 4.32-5.13). In multivariable models, factors associated for 72 h ED-visits were: age (aHR 1.06), male (aHR 1.14), Charlson Comorbidity Index (aHR 1.16), unscheduled hospitalization (aHR 1.39), prior consultation with the ED (aHR 1.08) and long hospital stay (aHR 1.39). Meanwhile, 2345 patients had at least one hospital readmission (98 % unscheduled), resulting a 24 h rate of 0.5 % (95 %CI 0.42-0.71), at 48 h 0.98 % (95 %CI 0.80-1.18), at 72 h 1.4 % (95 %CI 1.2-1.6); at 30 days 7.7 % (95 %CI 7.2-8.2); at 90 days 13 % (95 %CI 12.4-13.8); and one-year 22.5 % (95 %CI 21.7-23.4). Associated factors for HRR at 30 days were: age (HR 1.16), male (HR 1.09), Charlson comorbidities score (HR 1.27), social service requirement during First-H (HR 1.37), unscheduled First-H (HR 1.16), previous ED-visits (HR 1.03) and length of stay (HR 1.08).

CONCLUSION

Priorities efforts to improve must include greater attention to patients' readiness prior discharge, to explore causes of preventable readmissions, and better support for patient self-management.

A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit

BACKGROUND

The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions.

METHODS

We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach.

RESULTS

Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags.

CONCLUSION

Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

BACKGROUND

Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities.

METHODS

Participants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health and social service use and cost, from baseline to 6- and 12-months. Caregivers will be assessed for caregiver strain, depressive symptoms, anxiety, health-related quality of life, and health and social service use and costs. Descriptive and qualitative data from older adult and caregiver participants, and the nurse interventionists will be used to examine implementation of the intervention, how the intervention is adapted within each study region, and its potential for sustainability and scalability to other jurisdictions.

DISCUSSION

A nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population.

TRIAL REGISTRATION

# NCT03157999 . Registration Date: April 4, 2017.

Unplanned Readmission within 28 Days of Hospital Discharge in a Longitudinal Population-Based Cohort of Older Australian Women

This study aimed to estimate the incidence of 28-day unplanned readmission among older women, and associated factors. Data were used from the 1921–1926 birth cohort of the Australian Longitudinal Study on Women’s Health. Linkage of self-reported survey data with the Admitted Patient Data Collection allowed the identification of hospital admissions for each woman and the corresponding baseline characteristics. The Cox proportional-hazards model was used to identify factors associated with time to unplanned readmission, using SAS software V 9.4. (SAS Institute, Cary, NC, USA). Of 2056 women with index unplanned admission, 363 (17.5%) were readmitted within 28 days of discharge, and of these 229 (11.14%) had unplanned readmission. Among women with unplanned readmission, 24% were for the same condition as for the index hospitalisation. Cardiovascular diseases were the main diagnoses for the index admission and readmission. Unplanned readmission risk was higher if not partnered (hazard ratio (HR) = 1.43, 95% confidence interval (CI): 1.05–1.95), of non-English speaking background (HR = 1.62%, 95% CI: 1.07–2.47), more than three days length of stay on index admission (HR = 1.41%, 95% CI: 1.04–1.90) and one or two of the assessed chronic diseases (HR = 1.68, 95% CI: 1.19–2.36). At least one in ten women had unplanned readmission at some time between ages 75–95 years. Women who are not partnered, not of English-speaking background, with longer hospital stay and those with multi-morbidity, may need further efforts during their stay and on discharge to mitigate unplanned readmission.

The relationship between perceived difficulty and reflection in the practice of discharge planning nurses in acute care hospitals: A nationwide observational study

AIMS AND OBJECTIVES

To clarify the characteristics and practice of discharge planning nurses in acute care hospitals and to elucidate the relationship between subjective difficulty perceived in practice and reflection.

BACKGROUND

The importance of discharge planning for an effective transition from the hospital to a care facility is increasing. In acute care hospitals, however, it is not clear what discharge planning nurses are doing for patients who are highly dependent on medical treatment, the subjective difficulties they perceive in practical activities, and whether reflection by nurses can be expected to mitigate those difficulties.

DESIGN

Cross-sectional survey.

METHODS

This survey was conducted in 2,379 acute care hospitals in Japan from 1 June-30 June 2018. The survey of discharge planning practice activities examined nine factors. A nurse who answered that he/she did reflect on his/her practices was defined as a self-reflecting nurse. The STROBE statement checklists were completed.

RESULTS

Questionnaires were collected from 760 respondents (response rate = 32.1%). The discharge planning nurses had fewer than 36 months of experience with discharge planning. Among the nurses who had been involved in hospital discharge support for 13 months or more, the self-reflecting nurses had fewer perceived difficulties in their practice activities than the non-self-reflecting nurses did.

CONCLUSIONS

It was shown that discharge planning nurses with 13 months or more of experience and who practiced reflection on their practical activities perceived less subjective difficulty. Reflection in daily practice may mitigate the subjective difficulty of practical activities experienced by discharge planning nurses, and the establishment of an effective training method that promotes such reflection is required.

RELEVANCE TO CLINICAL PRACTICE

In the future, it will be necessary to construct and evaluate an effective education programme for discharge planning nurses that includes self-reflection on practice cases.

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease

OBJECTIVES

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center.

DESIGN

We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission.

SETTING

The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks.

PARTICIPANTS

Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol.

MEASUREMENTS

A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis.

RESULTS

Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89).

CONCLUSION

The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.