iim ORIGINAL. CONTRIBUTION Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders A Randomized Clinical Trial Mary D. Naylor, PAD Dorothy Brooten, PhD Roberta Campbell, MSN Barbara 5 Jacobsen, MS Mathy D. Mezey, BaD Mark V. Pauly, PhD ‘J Sanford Schwartz, MD HE CONTINUED GROWTH OF DI- agnosis related groups (DRGs) and capitated reimbursement for inpatient eare have increased pressures on hospitals to reduce length ofstay. Consequently, elders with com- plex health needs are being discharged {rom hospitals eatier."° Home health ser- vices and families have served as safety nets for many of these patients. How- ever, the rapid and dramatic growth of home health eare has recently resulted in decreased access to services. Poten- lial consequences for elders with sert- fous health problems include increased risk for preventable hospital readmis- sions and nursing home placement." Recent sitidies have evaluated inno- vative interventions to feiltate the ran sition of older adults from hospital to home.!*" Most of these efforts focused oneldershospitalized with specific health problems, such as congestive heart fail- ture (CHP). A randomized trial” that, we completed in 1992 demonstrated short-term reductions in readmissions and decreased costs of care for hospital- For edi comment see p 65 (©1909 American Medical Association. All rights reserved. JAMA, February 17,1999 Val 28 Downloaded From: on 10/23/2017 ‘Context Comprehensive discharge planning by advanced practice nurses has dem- onstrated short-term reductions in readmissions of elderly patients but the benefits (of more intensive follow-up of hospitalized elders at rsk for poor outcomes after dis- charge has nat been studied. ‘Objective Toexamine the effectiveness of an advanced practice nurse-centered discharge planning and home folow-up intervention for elders at risk for hospital readmissions. Design Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after in- dex hospital discharge. Setting Two urban, academically affiliated hospitals in Philadelphia, Pa Participants_Eligblepaients were 65 yearsor ler, hospitalized between August 1992 2nd March 1996, and had of several medial and surg reasons for admison Intervention Intervention group patients ecelveda comprehensive discharge pan- ning and home follow-up protocol designed special for elder at ik for poo oul Comes alter dicharge and implemented by advanced pracice nurses ‘Main Outcome Measures Reacmisions, ime to fist eadmision, acute care vis isafter discharge, cost, funclonal tatu, depresion, and pallentsisfaction. Results total of 363 patients (186 inthe contol group and 177 inthe intrven- tion group were enrolled in the study; 70% of intervention and 78% of contol sub- jects completed the tal. Mean age of sample was 75 years 50% were men and 45% rere blac By week 24 ater the index hora dachage, control group patients were ‘mot likely than intervention group patients tobe readmitted at east once (7.126 ve 320.3%; P&001), ewe intervention group patents had multiple admissions (6.2% 14.5%; P= 01) and the intention group had fewer hospital days er patient (1.53 vs days; Po-001, Time oft readmission was inereased inthe ntrven- tion group (P=.001). At 24 weele after dscharge, total Medicare reimbursements for health services were about $1.2 milion inthe control group v about $0.6 lion In the intervention group (2-003), There were no significant group dferencesn post discharge acute eae vs, functional satus, depression, or pallet sallsfaction Conclusions An advanced practice nurse-cenered dicharge planning and home Care intervention for atrsk Rosptalzed elders reduced readmisions lengthened the time between dcharge and readmission, and deceased the costa providing health care. Thus, the intervention demonstrated reat potetaln promoting postive out Comes for hospitalized elders at high sk for rehospitalizaon whe reducing costs dann. 99281612600 wwowiamacn ‘Author Aflations: Schoo of Nusing (Or Naylor Nursing, New York Univers, New Yor, NY (Or {2a Mss Campbel and Jacobsen), The Wharton Mezey ‘Shee (Or Pauly), ara_Sero0! of Medicine (Or Corresponding Author and Reprints: Mary O. ‘Scowara, Uversy of Perasyvana Phiadehia; Naylor, Pub, Univesity of Pennyivania, Schoo Snel of Nursing, Case Wester Reserve Uniersty, of Nuing 420 Guardan De, Phage, PA T3104 lerdane, Ohio (Or Brecten and Divion of ermal: ayorBpobox.upenn eu)FOLLOW-UP OF HOSPITALIZED ELDERS ized elders with medical cardiac eondi- luons managed according to a compre hensive discharge planning protocol implemented by advanced practice nurses (APNs). Findings suggested that elders at risk for poor outcomes alter dis- charge might benefit [rom more inten- sive home follow-up. The objective ofthis randomized cint- cal wil was to examine the effectiveness of an APN-centered comprehensive die. charge planning and home follow-up pro- tocol for elders hospitalized with 1 of sev- ‘eral common medical snd surgical reasons for admission. Based on our earlier re search, we hypothesized that this inter- vention would improve patient health out- comes and reduce service wilization and healthcare costs compared with usual hos- pital and home care METHODS: Study Sample The study was conducted at the Hospi- tal of the University of Pennsylvania and the Presbyterian Medical Center of the University of Pennsylvania Health Sys tem and was approved by the institu tuonal review boards at both snstita- lions. All subjects screened for study Figure 1s Patent How Diagram 614 JAMA, Febru 17,1999 Vol 281, No.7 Downloaded From: on 10/23/2017 participation were age 65 years or older and were admitted from their homes to either hospital between August 1992 and March 1996 with 1 of the following di- agnoses: CHP, angina, myocardial in- larction, respiratory tract infection, coro- nary artery bypass graft, cardiac valve replacement, major small and large bowel procedure, and orthopedic procedures of lower extremities. These diagnoses ‘wereamong the top 10 reasons for Medi- care beneficiary hospitalization in 1992." The DRGs were assigned at hospital d= mission and validated at discharge. Eligible patients had to speak En- alish, bealertand oriented when admit- ted, be able to be contacted by tele- phone after discharge, and reside in the ‘geographic service area, Patientsalso had to meet at least 1 ofthe following erite- ria associated with poor postdischarge ‘outcomes in out earlier study" age 80 years or oder; inadequate support sys- tem; multiple, active, chronic health problems; history of depression; mod- erate-to-severe functional impairment; multiple hospitalizations during prior 6 months; hospitalization in the past 30 days; fairor poor self-rating of health; of history of nonadherence to the thera- peutic regimen, (Of the 1296 patients sereened, 28% were enrolled, a percentage consistent with randomized clinical trials involv ing similar populations.» The 72% not enrolled comprised those discharged be- fore screening (20%) and refusals (43%) (FIGURE 1). Enrollees and refusals were similar in race (P=.00) and sex (P=.25). Mean ages differed by 2 years (75.4 years for enrollees vs 77.3 years for refusals, P<.001), Study Desi Patients were enrolled inthe study within 48 hours of hospital admission by re- search assistants (RAs) blinded to study ‘groupsand hypotheses. Aflersereening patients for eligibility and obtaining in- formed consent, RAs notified the project manager who assigned patients to study {groups using a computer-generated al- gorithm. The project manager con- {acted APNs if patients were assigned to the intervention group. Baseline data on (©1909 American Medical Assoc both groups (ie, sociodemographic and health status characteristies, functional siatus, and depression) were collected at ‘enrollment by RAs using standatdized in- struments (TABLE 1) Control Group. Control group pa Lients received discharge planning that was routine for adult patients at study hospitals. IFreferred, control group pa Lients received standard home care con- sistent with Medicare regulations Intervention Group. The interven- lion extended from hospital admission through 4 weeks after discharge. The [APNs assumed responsibility for dis- charge planning while the patient was hospitalized and substituted forthe vis- iting nurse (VN) during the fst 4 weeks alter the index hospital discharge. Over the course ofthe study, the protocal was implemented by 5 part-time, master's- prepared, gerontological APNs with a ‘mean of 6.5 years (range, 2-9 years) post- degree experience in hospital and/or home care of older adults. Intervention group patients and thelr caregivers, if available, received a stan- dardized comprehensive discharge plan- ning and home follow-up protocol de- signed specifically for elders at high risk for poor postdischarge outcomes. The protocol guided patient assessment and management and specified a minimum set of APN visits. However, an impor lant component of the intervention was the ability of the APN, in collaboration with the patient's physician, to individu- alize patient management within the bounds of the protocal The protocol was implemented as fol- lows: intial APN visit within 48 hours of hospital admission; APN visits least, ‘every 4 hours during the index hospi- talization; at least 2 home APN visits (1 within 48 hours after discharge, a sec ond 7-10 days after discharge); addi- Lional APN visits based on patients needs with no limit on number; APN tele phone availabilty 7 days per week (8 AML lo LOPMon weekdays and 8 AM to noon fon weekends); and at least weekly APN- initiated telephone contact with pa Lents of caregivers. Hospital Visits, The APNs used data, generated from instruments of estab- ton, All rights reserved,lished validity and reliability (Table 1) and thet clinical skilsto dently patiente’and caregivers’ discharge needs, Assessment focused on nature and severity of health functional, cognitive, and emotional health status; and discharge goals, Caregiver as- sessment also included social support, knowledge and skills, strain and need for formal support. Based on this infor- ration, APNs collaborated with the pa tient, physician, caregiver, and other team ‘members in designing sn individualized discharge plan, The APN implemented the plan through direct clinical care, patient and caregiver education, validation of learning, and coordination of needed home services, The APNs attempted to schedule hospital meetings with cate givers present. Within 24 hours of dis- charge, physicians wrote discharge orders and APNs scheduled the initial, home visi. Home Visits, Telephone Availabil- ity, and Outreach. The APNs com- pleted physical and environmental as- sessments and ta Increasing patients’ and ent lay to manage unresolved health prob- lems. Based on individual needs, APN in- ed efforts at vers abil- Letventions focused on medications, symplom management, diet, activity, sleep, medical follow-up, and the emo- tional status of patients and caregivers, [A variety of strategies reinforced teach- ing including written instructions and medication schedules. Through home Visits and telephone follow-up, APNe ad dressed questions or concerns [rom pa Lents, caregivers, of health team mem- bers; monitored patients’ progress; and collaborated with physicians to make ad: justments in therapies and obtain reler- rails for needed services, Discharge Summaries. At comple- liom of the intervention, APNs sent writ- len summaries Lo patients, cat physicians, and other providersto whom [APNs had referred patients, detailing the plans, goal progression, and ongoing Outcome Measures ‘Outcome measures included hospital re- admissions related to any cause, recur- (©1909 American Medical Association. All rights reserved. Downloaded From: on 10/23/2017 FOLLOW-UP OF HOSPITALIZED ELDERS intervention sa A 6 3 u 3 orn a Saree Son 8 ir a aR i =| i 2 i inom Tato a 2 ooo a =| a 7 3% ima 7 z Dageae not Ta tn iv Sonar at at wm rary 7 ta aa ay aE GE iar pa 7 eager aa Ena mar ia a oa GA TTT ESTO TOTTORI Sacta hag Sie, soa ad a as raw 8 3% Say pase nea Tao THT Gece a a Bs TET aT Tomcentae jaar ia ein RATA SST Tae Regt la a ca Tat Fast ceca nr Po past SOT 7 a7 ao Pea confor oats io ot day medoatons S2az Felons satus based ong Eoroad ‘Social Depend Seale"# Persona 145464 146460 Sect 942, a0a28 Tota a8. Bae. JAMA, February 17,1999 Val 28 ‘Socademograpive and Health Characters of Elceny Patients (N= 363) 18 7 se 56 a 78 780 a ro co 3 oy 0 78 36FOLLOW-UP OF HOSPITALIZED ELDERS rence or exacerbation of the index hos- pital fornew health problems, The primaty in- tervention ellicacy test was defined on, the basts of time to first readmission for any reason, Secondary outcomes were cumulative days of rehospitalization, ‘mean readmission length of stay, num- ber of unscheduled acute care visits af- ler discharge, estimated cost of postin- dex hospitalization health services, functional status, depression, and pa- Lient satisfaction, Outcome data were col- lected by RAs blinded to study groups and hypotheses. Standardized telephone interviews with patients at 2, 6, 12, and 24 weeks after index hospital discharge identified patients'readmissions tony hospital and lunscheduled acute care visits to physi- cians, clinies, and emergency depart- ments. Data on functional status (mea- sured by the Enforced Social Dependency Scale), depression (assessed using the Center for Epidemiologie Studies Depres- sion Seale), and patient satisfaction (measured by an investigator-devel- oped instrument) were also collected dlring these interviews, Data on the number, timing, reasons, and charges for teadmissions, unsched- tled acute care visits, and home visits by \VNs or APNs (intervention group only), allied health professionals, and assistive personnel were abstracted from pa Lents records inpatient, outpatient, and home care) and bills and recorded on ion DRG, comorbid conditions, standardized data collection forms. Rea sons for readmissions were validated in \writing by patients’ physicians. The RAs categorized the reasons using discharge diagnoses as index-related (discharge i- agnosis same as index hospitalization) comorbid (discharge diagnosis 1 of co- morbid conditions identified at index hospitalization); or new health prob- lem (not related to index diagnosis or co- morbid condition during index admis- sion). Estimated resource costs were generated using standard reimbursements, Costs of pharmaceuti- cals, over-the-counter drugs, assistive de- Vices, other supplies, and indirect costs (cg, productivity losses by patients and caregivers) were not included, Medicare (616 JAMA, Febesny 17,1999. 251, No.7 Downloaded From: on 10/23/2017 Statistical Analysis For patients who did not complete the entire 24-week postindex hospital zation study period (death or with- drawal), data collected between random tzation and withdrawal were used inthe analyses, performed according tothe i- tention-to-treat principle, and cen- sored at time of death or withdrawal Baseline daa for intervention and con trol groups were compared using tests for categorical variables, tests for nor- mally distibuted continuous variables, and the Wileaxon rank sum test fr ab- rormaly distabuted variables, Based on a por clinical tal,” we estimated that in each ofthe 2 study groups, 125 pac tients had to complete the study to de tect a 50% reduction in hospital admis sion ates (2-sided 05 al power 0.90, ‘pase on a contol group readmission rate 010.30)" Descriptive comparisons between, sroups used x? tests for the proportions of patients readmitted, {tests oF Wile coxom rank sim tess for numberof e- admissions, total days of hospitaliza- UUon, mean readmission length of say, rmumber of acute care Visits, and relm- >bursements for posidischarge health ser- vices: Multivariate analysis of variance tested for measures of functional status, depression, and patient satisfaction. Kaplan-Meier survival curves” were used to compare control and interven Lion groups to account for uneqial fl- low-up times forthe primary end point of time to est readmission for any rea- son and the secondary outcomes of time to first index-related readmission and lume to lirst readmission or death, Crude testingof the primary hypothesis that the 2 cumulative readmission-re rate curves ‘were identical was performed using log- rank slatistic.” Potentially confound- ing variables were adjusted using pro- portional hazards regression,” providing anadjusted hospital readmission rate m- Uo (ineidence density ratios) along with 9586 confidence intervals (Cl). final rmulivarate model included covariates relaining their bivariate significance (P<.05) along with intervention group tw obtain adjusted significance levels and adjusted risk estimates with 95% Cl, Variables were removed in a stepwise manner. Intervention group interac lions with significant index diagnoses were assessed by adding appropriate terms to the model. Group dilferences in both charges and actual Medicare reimbursements for postindex hospitalization health ser vices were examined, The more con- servative reimbursement results are re- ported, Although reimbursements are not the same as costs, they are a reasonable proxy and provide reasonably unbiased estimates of relative differences in cost between intervention and eontrol groups. The index hospital reimbursement in- cluded the costs of discharge planning services provided by registered nurses, social workers, and discharge planners. Since the APN hospital visits in this n= lervention substituted for standatd dis- charge planning, noaddltional costs were assigned to this phase of the interven- lion, The cost of APN services after dis- charge was estimated by assessing APN Intervention-related effort (from de- tailed logs) and applying Medicare re- lmbursement rates. Inthe primary analy- sis, postdischarge APN and VN services were assigned the same rte since this re- fected Medicate’s reimbursement dur- ing the study period. Sensitivity analy- ses were conducted using higher estimates for APN services (actual APN reimbursement plus 20%), reflecting their increased skill and raining rela- live to VNs, and representative annual salary for APNs plus benefits was weighted by percentage of effort attrib tlable to the intervention. RESULTS Study Patients A o1al of 363 patients were enrolled in the study (Table 1). The 2 study groups \were similar in all sociodemographic and baseline health characteristics, includ- ing index hospitalization DRG, type of admission, and length of stay. Mean age of the entire sample was 75 years, 50% were men, and 45% were black. ‘The attrition rate from the snterven- tion group (including deaths) was 30% (S¥V/177) compared with 26% (48/186) forthe control roup (P= 26). Of the 363, (©1909 American Medical Association, All rights reserved,enrolled patients, 22 (6%) died by 24 weeks alter discharge, with 11 deaths in ach of the 2 study groups (Figure 1). Most of the deaths occurred during the index hospitalization or in the first 6 weeks alter discharge (4% control, 5% intervention). An additional 4% in each ofthe study groups withdrew because of inability to complete follow-up inter views (changes in health status such as stroke or cognitive decline). The remain- ing withdrawals (16% control, 20% in lervention; P= .64) occurred because pa- ents changed their minds about participating (13% control, 18% inter- vention; P=.28); moved away (1% con- trol, 1% intervention); oF were dis- charged toa nursing home (2% contro, 1% intervention). Intervention group withdrawals were slightly higher be- cause a few patients in this group de- cided, after enrolling, to maintain exist- ing VN relationships and services ‘Study follow-up did not differ sigit- cantly between control and intervention, groups (18.1 weeks vs 19.1 weeks; AL). The 28% attrition rate was con- sistent with rates reported in other ran- domized clinical trials with a simular pa Lient population." The 262 patients \who completed the study and the 101 per- sons in the altrition group did not signili- cantly differ in sociodemographic vati- ables and severity of illness measures (eg, number of comorbid conditions). Readmissions Control group patients were more likely {han intervention group patients to be re admitted at least once (TABLE2; 37.19% vs 20.3%; P<.001;relativerisk,1.8;95% Cl, 1.3-2.6). The 16.8% absolute reductionin hospital eadmisstons at 24 weeks repre sented 45% relative reduction in control sgroupreadmission rate. More control group patients had multiple readmissions dur- Ing the 24-week period than intervention group patients (14.5% vs 6.2%; P= 01. relative risk, 2.3;95% Cl, 1.2-4.6) The intervention resulted in fewer to- tal hospital readmissions at 24 weeks af- ter index hospitalization discharge (107 control vs 49 intervention; rank sum test, P<,001), The reduction in readmis- sons was signifieant during both the frst. ‘6 weeks after discharge (P<.001) and the -week to 24-week period (P=.02). Of the 156 readmissions, 60.3% were related to the index hospitalization, 22.4% to comorbid conditions, and 17.3% to new health problems, There c fewer readmissions related to the index: hospitalization in the interven- von group compared with the control group (30 vs 64; P=.005). There were trends toward reduced intervention ‘group teadmissions due to comorbid conditions (10 vs 25; P=.06) and new health problems (9 vs 18; P=.10). ‘A124 weeks, control group patients ex perienced 760 days of hospitalization, compared with 270 days in the inter- vention group (P<.001). Hospital days per patient were higher in the control ‘group compated with the intervention group (4.09 vs 1.53; rank sum test, Pe<.001 [with or without adjustment for Follow-up time)). The mean length ofstay for readmitted patients in the control group (n= 69) was higher than the in- FOLLOW-UP OF HOSPITALIZED ELDERS tervention group (n=36), (11.0 10.6 days vs 7.5448 days; P<001). Time to first readmission for any’ rea son was increased in the intervention group (log-rank x= 11.1, P<.001) (FIGURE 2). Twenty-five percent of con- trol patients were readmitted within 435 days after index hospital discharge (95% Cl, 34-63 days), whereas 25% of inter- vention patients were readmitted within, 133 days lower 95% confidence limit, 78 days; upper 95% confidence limit, notesti- rable). The effect of the intervention on lume to first readmission for any reason, remained significant (P<.001, TABLE 3) alteradjusting or simultaneously signifi- cant variables including self-reported health status, number of hospitalizations inthe previous 6 months, living arrange rents, and diagnosis of CHE. The ume to index diagnosis-related readmissions similarly was increased in the interven tion group (log-rank x*,=4.97, P=.03), Statistical evidence was weak that the relative ellicacy dilfered betw en pa- ‘Table 2, Readmssone and Hospital Days Wit From Index Hospitalization ‘o-Pa ot pater reacted Tin 26 (203) Times Tea No: atreadimiatone 20 0 7 @ Tire of escasons, ‘ischarge to 6 wk 7 Brozawe 2 Tih spent heap @ ‘a er pan roan = SD Magan hPa 50h Percent Toth Pernt arrest patent, TSOTAT mean + SDP ‘Megan co 2ahPaania a SahParcent co Tat Pernt i (©1909 American Medical Association. All rights reserved. Downloaded From: on 10/23/2017 fin 24 Weeks of Decharge Contra (oa 186) 6997.1) BTS) ot 2 72 7 TOTS TORT “aa JAMA, Febery 17,1999 Nol 28FOLLOW-UP OF HOSPITALIZED ELDERS tients with and without CHP ( ingcensored wasexamined, ime until firs departments, or home visits by VNs or 11). The crude rates for any read readmission for any reason remained in- APNs,alied health professionals or home mission per year among control and in- creased inthe intervention group (rate ra-_healthaides TABLE4).The patiemofhome tervention patients without CHP diag- tio, 16; 95% Cl, 11-23; P= 01), \isisby nursesimmediatelyalterindexhos- nosis were 1.17 (41 event35.2 years) pital discharge dilfered between study tnd 042 (16 events/38 years), respec- Other Patient and Health sroups. Only44% ofthe control group re- Lively, for a crude relative rate of 28. Services Outcomes ceived at east 1 home visit by VNs during ‘Among CHF patients, the crude control Interventionandcontrolgroups weresimi- thelist weeksafter discharge. Consistent and intervention group admission rates larinmean functional status(P=.33),de- with thestudy protocol all ofthe interven- per year were 1.93 (25 events/13 years) pression scores P= 20), and patient sat- ion group receivedat least 1 APN visit. Of and 1.45 (19 events/12.8 years) respec- ishction(P=.92).AL24weeks, mean func- the 69 contzolpatensrchosptalized atleast, Lively, fora crude relative ratio of 1.30. onal status scares in both groups were once,51%receved VN vss during them Inclinical terms, however, the interven _slghly improved over baseline (21.5 to mediate postdischarge period Lion's relative efficacy was sigeiicantly 19.2)aswere mean depressonscores(10.7 larger for patients without CHE com- to 6.6). Mean patient salsfaction scores Eeonomic Impact pared with patents with CHF Gate a showedlitlechngeovertime;bothgroups At 24 weeks, otal and per-patient inn to, L6¥8 27) remained highly satisfied with ear. puted reimbursements for postindex Relative elficacy did not depend on At24weeksalterdischaege,the control acute health services nthe contol group study ste for time wo any fest admission andimterenton roupsddnotsgaficanly were approximately twice as much asthat 22). Whenaseeondaryend pointde- difeinthemear number ofunscheduled ofthe intervention group ($1 238925 vs fining deaths as an event rather than be- _acutecareVsstophysicansoremergency $642 595 [P<001 and $6661 v3$3630 [P<001]; TABLES). Intervention group cost savings were driven by the conteol sroup’s substantially greater total DRG reimbursements for ll hospital sions at 24 weeks after discharge ($1024 218 vs$427 217, P<001). sub- + nosy stitution of charges adjusted charges and he Weighted APN average annual salary and t benefits for reimbursements as mea- sires of resource use further increased Figure 2. Time to Fist Hospital Readmission for Any Reason wdimis- § 0s. =~ the estimated differences between groups. Boe Total reimbursements for other postdis- $02) [axeunannesrm charge acute care visits Were not sig Bau] [Smee ton cantly different between study groups ee (Table 4; P=.72) TE a COMMENT ser ocergn & This study demonstrated that a compre- ‘Tha live readisson als comparing te contol woup with he hleverton goup ae 196 95% op. hensive discharge planning and home fo Fence terval (CN, 131-25) fr the crue fate and 203 (957. Cl, 134-308) fhe aduste ate The low-up intervention designed speci Survival cuve distances P= 01 (elated wih the gan est, cally for elders at high risk for poor posthospital discharge outcomes and ‘Table 3, Tine to Fat Hospital Readrsrion by Prbent Characenrice (Mlivarate ax’ mmplemented by gerontological APNsre- Propertonal Hazede Mode) duced hospital readmissions, length- rida Daraty 5% Confidenes PB ened the time to first readmission, and Variable Ratio Inteval decreased cost of care. Improved pa- ‘aie aro sinenenion ome 205 1aeS08 Uent outcomes and health care savings Far orpocr sa rang ve good zie 1335 vent demonstrated whet a obama ang have aso een demonstrated whe 3 ee ee stl appronch to care was tested with pos bo. women with high-risk pregnancies and ig with lative or ane ap aa oar @_low-birth-weight infants" Tigh live a and 30 ozo G5 By 24 weeks alter the index hospital Congest hea fire ve thor oc Torza T discharge, 37% ofthe contol group had “dagnoe ltd rue been chosptalized compared with 20% 618 AMA Febuary 17,1999 Vol 281, No.7 (©1099 American Medical Assocation. Al rights reserved. Downloaded From: on 10/23/2017ofthe intervention group. Although non- randomized studies!" have demon- strated greater reductions in rehospital- ation rates for adult eardiae patients, only 1 randomized clinical trial, limited lo patients with congestive heart fail- ture, demonstrated a similar absolute re admission rate reduction.” In contrast to this study that included rehospital- izations to any hospital, other studies have examined only readmissions to study hospitals” or did not specify if re- admissions to hospitals other than study hospitals were included.» Study findings are especially impor lant given the current attention to new models of patient cate management. In contrast to the typical disease manage ‘ment model that focuses on all patients hospitalized with a specifi primary con- dition, such asheatlsilure, thisinterven- ton targeted elders hospitalized with com- ‘mon medical and surgical conelitions. We believe thatthe focus ofthe clinical inter- vention on the combined elects of pri- rmaty health problems, comorbid comdi- tions, and other health and social istues common in this patent population, rather than on the management of a single dis- cease, was a major factor i its success ‘Other factors may have contributed to these observed outcomes, The target study population, elders at high risk for poor outcomes after hospital discharge, \was not limited to those who met cur- rent Medicare home-care eligibility te quirements. Approximately one third of control patients who did not receive a Visit froma VN immediately alter the in- dex discharge were rehospitalized. The factors that influence health profession- als decision making regarding which pa UUentsare referred for home eae isa im portant area for further study. Home Visits alone, however, de not explain the dillerences in group outcomes demon- strated inthis study. One in 2 control pa Lients visited by VNs immediately alter the index hospital discharge were rehos- pialized compated with 1 im 5 interven tion patients visited by APNs. ‘While the protocol tested inthis study rch, the framework that guided APNs decision making was individualized care, In con- was derived from current rese (©1909 American Medical Association. All rights reserved. Downloaded From: on 10/23/2017 trast to most VNs who are bachelor's: prepared generalists, the APNs who implemented this protocol were masters prepared specialists in gerontological This intervention benelited from APNs clinical acumen as well as their ex- pertise in communicating, collaborat- ing, and coordinating care with physt- FOLLOW-UP OF HOSPITALIZED ELDERS cians and other healthcare professionals For example, a preliminary analysis of APNs’ case studies suggests that joint clinical decision making with physt- cians resulted in timelier interventions inthe home and prevented negative out- Unlike home eare nurses, whose visit ‘Table 4. Acute Care Visits, Home Vist, and Retmbursements (Costs) for Health Services, ‘After Discharge for 24 Weeks Tatervenion ‘Contr a wet Cary Values th Service Vistst Gosts,$_" Visitst Costs,s| site Cost Fesiacare vets Physica otice 18422 aoa? 1642227121 $0 mergenay depareney O1s05 O18 O2s04 10600 at Fama vais Nurses Viste 1472 a00a7 744120 101049 05 05 Raenceipacice 055435 e600 0_= 00 = oF Revancodpracice T6=04 ore? 71s 120 1O1OWw 65 73 and vsting Piya tana Sree Geo _STs 8s Aas ais09 01 Specitiwapsts 008205 a Sccal wore 006203 67 Obata 182 Frome ath aes S78 W1esaee 25 ates ‘Tal Wate and Coste OAs Ts92280 AAO Hecan z in Pecan a ah Parcenta a {ican So nanbe ofrecer hes at 0.2) ‘Table 5. Reimbursements (Cost) for Readmissions, Acute Care isis, and Home VsIS| f0r24 Weeks After Discharge Health Service| Fasaristone ‘ex rlated ea Comores 10 New problems i ‘Total Readmesione Bara Toeaaie Dot ‘tke care vis (phyicars oc, HOTS Ta 7! cy partner Fama vate Nurses 01607 s01049 72 Share Toeoe Teaad 70 Taal Biz FEET DoT arpa = Br Dat JAMA, Febery 17,1999 No 281, No.7 619FOLLOW-UP OF HOSPITALIZED ELDERS pattern is constrained by reimburse ‘ment and other barriers, APNs sed their judgment to define the frequency, im- tensity, and focus of contacts needed to meet patient and caregiver needs, Con- sequently, the time and focus of se vices provided by the APNs varied. Punctional slatus was not improved with this intervention, a finding consis- tent with published data from other dis- charge planning and home eare studies in recent years. Reductions in rehos- pitaizations and cost in the absence of differences in functional status may in- dicate that the APN-based intervention achieved its henelit by enhancing the ca- pacity of high-risk elders to better cope ‘with their muluiple medical problems and disabilities.” Mean scores at al data col- lection points revealed lite depressive symptoms in this study sample.** The skewed distribution of pa- Lent satisfaction scores suggests the need for more sensitive tems, AL 6 months, the intervention gene sted estimated savings in Medicare r Imbursements for all postindex hosp- tal discharge services of almost $600 000 for the 177 intervention group beneli- ciaries,a mean per-patient savings of ap- proximately $3000. Thus, the interven- tion was dominant from’ an economic perspective—improved outcomes were achieved at reduced cost, Virwally all of the savings resulted from reductions in rchospitalizations, with use of nonhos- pial postdischarge health services simi- lar in intervention and control groups When extrapolated to the number of older adults hospitalized each year with similar conditions, the potential patient benefits and savings to the Medicare sys- tem resulting from this intervention are substantial vidence of In conclusion, an APN-centered dis- charge planning and home care inter- vention forat-risk, hospitalized elders re- duced readmissions, lengthened the ume between discharge and readmission, aid decreased the costs of providing heath care. This intervention has great poten- Lal in promoting positive outcomes for this challenging group of elders while re- ducing costs, 620 JAMA, Febeury 17,1999 Vol 281, No.7 Downloaded From: on 10/23/2017 Funding/ Supports Funding was povided the Ne {ional iste or Nursing Research ofthe National Institutes of Healt, Bathesce, Ma, grant ROT 'NR02095. Br Nayar wa the princi investigator. ‘Acdnowiedgmen: Weare eto APisorther ‘xtaornaty comment in sccompleng the ge tissue) Spcalecopions genoa Foust PhO, RN, and Caterne Wollman, MSN. CRNP, no ere inoledwoughout he ertestudy etd We ‘othank Greg Mastin, MS, MA. pial sas {ian Bomasta Stattal Conan Wynewood, a. fers gun. The suppor provided by up of declarer stants deep spores Fray, we than Caan Stephens Cea, irs Maris, MSEd and ato Bes, PD forthe Slane nthe completo ofthe manuscript. RNS 4. Grays, National Centro Heh Stats: No ina Hospal Dscharge Survey: anual summary, 1993, Veal Heath Sa 12 1998248, 2. 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Heath Outcome for Oder People Questions forthe Coming Dcade Fel ‘ued Washington, DC Natnal esdemy Pres 1956. (©1909 American Medical Association, All rights reserved,