ABSTRACT
The continued growth of diagnosis related groups (DRGs) and capitated reimbursement for inpatient care have increased pressures on hospitals to reduce length of stay. Consequently, elders with complex health needs are being discharged from hospitals earlier.1-3 Home health services and families have served as safety nets for many of these patients. However, the rapid and dramatic growth of home health care has recently resulted in decreased access to services.4-6 Potential consequences for elders with serious health problems include readmissions and nursing home placement.7-11
Recent studies have evaluated innovative interventions to facilitate the transition of older adults from hospital to home.12-17 Most of these efforts focused on elders hospitalised with specific health problems, such as congestive heart failure (CHF).12-14, 17
A randomised trial17 that we completed in 1992 demonstrated short-term reductions in readmissions and decreased costs of care for hospitalised elders with medical cardiac
conditions managed according to a comprehensive discharge planning protocol implemented by advanced practice nurses (APNs). Findings suggested that elders at risk for poor outcomes after discharge might benefit from more intensive home follow-up.
