Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial

Report to Congress on the Evaluation of Medicare Disease Management Programs
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Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial

Context: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. Objective: To examine the effectiveness of an advanced practice nurse–centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. Design: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. Setting Two urban, academically affiliated hospitals in Philadelphia, Pa. Participants: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. Intervention: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. Main Outcome Measures: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. Results A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1% vs 20.3%; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%;P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in postdischarge acute care visits, functional status, depression, or patient satisfaction. Conclusions: An advanced practice nurse–centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus

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