Follow-up Reduces Hospital Readmission, Cost

Elderly patients at high risk for poor outcomes after hospital discharge who received comprehensive discharge planning and home follow-up implemented by advanced practice nurses were hospitalized less often, less quickly, and at far less Medicare cost.

These were the findings of a study recently published in the "Journal of the American Medical Association" by Dorothy Brooten, dean of CWRU's Frances Payne Bolton School of Nursing, and Mary Naylor, associate professor of nursing at the University of Pennsylvania. The National Institutes of Health's National Institute for Nursing Research (NINR) funded the four-year study for more than $1.2 million.

"Discharge planning is often not tailored to individual patient needs," Brooten said. "In addition, home follow-up by advanced practice nurses familiar with the patient's past progress has made a significant difference in this study and others where we have applied the same approach."

In 1980, Brooten developed a pioneering transitional care model that has demonstrated significant reductions in health care costs for high-risk, high-cost patients. The model was the basis for the recent NIH study. Advanced practice nurses with master's degrees provide comprehensive discharge plans and home follow-up and are routinely on call for patients. The patients' physicians back the nurses.

When Brooten created the model, hospitals were beginning to discharge patients earlier to help reduce costs, and no one was assessing whether patients were being rehospitalized, how quickly rehospitalization was occurring, and at what cost, she said.

"Some vulnerable groups of patients like the elderly were falling through the cracks with managed care," Brooten said. "The costs of rehospitalization were prohibitive, and the quality of patient care was a concern."

Brooten's transitional care model provided continuity of care for vulnerable groups by matching advanced practice nurses who had specialized skills in working with the vulnerable groups.

"The model was a way to develop a safety net for very vulnerable groups while addressing controls on health care costs," she said. "It was a method to examine the quality of health care as reflected in patient outcomes and costs."

The randomized clinical study involved 363 patients age 65 and older from two hospitals in Philadelphia. Of these, 186 were in the control group and received standardized care while 177 received the comprehensive discharge plan and home follow-up by advanced practice nurses.

The participants were at risk for hospital readmission because they had multiple, active, chronic health problems; inadequate support systems; were age 80 or older; had a history of depression; moderate-to-severe functional impairment; multiple hospitalizations six months prior to their participation in the study or a hospitalization 30 days prior their involvement in the study; fair or poor self-rating of their health; or a history of non-adherence to their medical therapy.

Within 48 hours of their hospital admission, the patients were enrolled in the study. An advanced practice nurse visited the patient every 48 hours during the hospitalization and worked with the patient, the physician, the caregiver, and other team members to design a discharge plan specific to the patient.

Upon discharge, the patients in the intervention group or their caregivers received a standardized comprehensive discharge plan. This included a list of medications, limitations to activities and acceptable activities, a plan for increasing the activities of daily living such as dressing and bathing, methods to monitor weight gain and loss, and triggers that might detect excessive fluids. The plan also provided information on the possible effects of medication, what signs to look for, and when to report problems.

The intervention extended from hospital admission to four weeks after discharge. The advanced practice nurse visited the patient within 48 hours of discharge and then again between seven and 10 days following discharge. After that the number of visits were based on patients' needs. The nurse telephoned the patient or caregiver once a week, was available seven days a week for consultation, and worked with the patient's physician to adjust treatment or obtain referrals for services if needed.

The study showed that six months after the patients were discharged, 20.3 percent of the group working with advanced practice nurses were rehospitalized, compared to 37.1 percent of the control group. Fewer of the intervention group (6.2 percent vs. 14.5 percent) had multiple readmissions. The patients receiving nurse follow-up also were able to remain out of the hospital longer before being readmitted. The difference in total Medicare costs between the two groups also was significant -- $1.2 million for the control group versus $0.6 million for the other group.

To date Brooten's transitional care model has been applied to several groups -- very low birth weight infants, women who had emergency cesareans, women with high-risk pregnancies, women who had a hysterectomy, elderly patients with cardiac medical and surgical conditions, and elderly patients with common medical and surgical conditions. Study results have been published in the "New England Journal of Medicine", "Obstetrics and Gynecology", and the "Annals of Internal Medicine", among others.

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