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

Context Comprehensive discharge planning by advanced practice nurses has de monstrated short-term reductions in readmissions of elderly patients, but t he 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-center ed discharge planning and home follow-up intervention for elders at risk fo r hospital readmissions. Design Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks a fter 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 reas ons for admission. Intervention Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at r isk for poor outcomes after discharge and implemented by advanced practice nurses. Main Outcome Measures Readmissions, time to first readmission, acute care v isits after discharge, costs, functional status, depression, and patient sa tisfaction. Results A total of 363 patients (186 in the control group and 177 in the in tervention group) were enrolled in the study; 70% of intervention and 74% o f 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 discharg e, control group patients were more likely than intervention group patients to be readmitted at least once (37.1% vs 20.3%; P < .001). Fewer intervent ion group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and t he intervention group had fewer hospital days per patient (1.53 vs 4.09 day s; P < .001). Time to first readmission was increased in the intervention g roup (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 significan t 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, le ngthened the time between discharge and readmission, and decreased the cost s of providing health care. Thus, the intervention demonstrated great poten tial in promoting positive outcomes for hospitalized elders at high risk fo r rehospitalization while reducing costs.