ABSTRACT
This study demonstrated that a comprehensive discharge planning and home followup intervention designed specifically for elders at high risk for poor posthospital discharge outcomes and implemented by gerontological APNs reduced hospital readmissions, lengthened the time to first readmission, and decreased cost of care. Improved patient outcomes and health care savings have also been demonstrated when a similar approach to care was tested with women with high-risk pregnancies and low-birth-weight infants.31-33
By 24 weeks after the index hospital discharge, 37% of the control group had been rehospitalised compared with 20% of the intervention group. Although nonrandomised studies12, 34, 35 have demonstrated greater reductions in rehospitalisation rates for adult cardiac patients, only 1 randomised clinical trial, limited to patients with congestive heart failure, demonstrated a similar absolute readmission rate reduction.13 In contrast to this study that included rehospitalisations to any hospital, other studies have examined only readmissions to study hospitals34 or did not specify if readmissions to hospitals other than study hospitals were included.13, 35
Study findings are especially important given the current attention to new models of patient care management. In contrast to the typical disease management model that focuses on all patients hospitalised with a specific primary condition, such as heart failure, this intervention targeted elders hospitalised with common medical and surgical conditions. We believe that the focus of the clinical intervention on the combined effects of primary health problems, comorbid conditions, and other health and social issues common in this patient population, rather than on the management of a single disease, was a major factor in its success.
