A transitional care service for elderly chronic disease patients at risk of readmission

Brand, Caroline; Jones, Catherine; Lowe, Adrian J.; Nielsen, David A.; Roberts, Carol A.; King, Belinda; Campbell, Donald

doi:10.1071/ah040275

Cited by 41 publications

(90 citation statements)

References 22 publications

(21 reference statements)

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“…15 The implementation of these services was associated with a decrease in attendances by older mented in other parts of the country with varying success. [16][17][18][19][20][21][22] The quintessence of such services is an integrated, multidisciplinary approach to assist in the acute hospital and post-discharge care of older people at risk of repeated hospital presentations. The emphasis has been on returning these patients to and maintaining them in the community.…”

Section: Discussionmentioning

confidence: 99%

Local trends in emergency department attendances by older patients in an ageing national population

Chu

Brown²,

Lukin³

2009

Aust. Health Review

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Nursing-led aged care services were set up at our Emergency Department (ED) in 2004-05 to assist in the appropriate discharge of older patients. This study examined local trends in ED attendances by older patients. A retrospective study was conducted at an inner-city adult ED in a region with a 2.2% annual growth rate. Patient demographics, Australasian Triage Scale (ATS) category and admission/discharge status were collected from January 2002 to December 2006. Total ED attendances increased 7.7% from 66 687 in 2002 to 71 801 in 2006. Older patients' attendances, however, decreased 3.1% from 12 356 to 11 971. This decrease in ED attendances by older patients was unexpected. This may represent local population trends and/or be related to ED services designed to manage older patients and nursing home residents in the community. The planning of health services for older people therefore needs to take into consideration the influences on local trends in Population ageing will impact on the demand for and provision of health services. Data from the Australian Bureau of Statistics (ABS) National Health Surveys revealed that 38% of people aged 65-75 years visited their doctor in the 2 weeks before interview, and that 23% had been hospitalised within the previous 12 months. 2 Compared with younger age groups, older patients may require different types of care in hospital. 3 The proportion of episodes for rehabilitation, geriatric evaluation and management, and maintenance care all increase with age. Despite their relatively greater need for nonemergency and critical care, the emergency department (ED) is likely to remain an important point of entry into the health care system for many older people.A cross-sectional study in 2001 at our ED has shown that older patients used relatively more ED resources than younger patients. 4 What is known about the topic? Ageing of the Australian population is well recognised, with older adults increasing their use of emergency departments (EDs). What does this paper add?This paper examined trends in attendances for older (у 65 years) and younger (14-65 years) patients, finding a decrease in ED presentations, but that admissions for older ED patients remained relatively stable at 1 in 2 patients. What are the implications for practitioners? Our data suggest that the number of presentations by older patients could decrease in certain regions, influenced by a dilution effect of a younger population and possibly by a "healthier older migrant" effect plus local nurse-led aged-care programs in the ED. The planning of emergency health services needs to take into account the influences on local trends in changing population demographics.

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Section: Discussionmentioning

confidence: 99%

Local trends in emergency department attendances by older patients in an ageing national population

Chu

Brown²,

Lukin³

2009

Aust. Health Review

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“…57 A similar negative result was noted in an Australian trial involving 166 high-risk older medical patients who were reviewed by a chronic disease nurse consultant before discharge and then seen again at a nurse-led clinic within two weeks of discharge. 58 Another trial evaluated a re-engineered hospital discharge program which centred on a nurse advocate who closely liaised with patients and carers during hospital stay, arranged follow-up appointments, undertook medication reconciliation, conducted patient education with an individualised instruction booklet (that was also sent to their primary care provider), and provided a written discharge plan combined with a telephone call from a clinical pharmacist 2-4 days after discharge to reinforce the discharge plan and review medications. 59 This resulted in a significant 30% decrease in hospital utilisation (ED visits and readmissions) at 30 days after discharge (P = 0.009), with a nonsignificant trend towards lower readmissions (28% decrease, P = 0.09).…”

Section: Studies Of Integrated Pre-and Postdischarge Multicomponent Imentioning

confidence: 99%

“…Hospital clinical directors and managers will need to negotiate the extra funding, personnel and stakeholder buy-in required to allow such programs to operate successfully. 58 …”

Section: Practice Implicationsmentioning

confidence: 99%

Preventing the rebound: improving care transition in hospital discharge processes

Scott

2010

Aust. Health Review

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Background. Unplanned readmissions of recently discharged patients impose a significant burden on hospitals with limited bed capacity. Deficiencies in discharge processes contribute to such readmissions, which have prompted experimentation with multiple types of peridischarge interventions.Objective. To determine the relative efficacy of peridischarge interventions categorised into two groups: (1) single component interventions (sole or predominant) implemented either before or after discharge; and (2) integrated multicomponent interventions which have pre-and postdischarge elements.Design. Systematic metareview of controlled trials. Data collection. Search of four electronic databases for controlled trials or systematic reviews of trials published between January 1990 and April 2009 that reported effects on readmissions.Data synthesis. Among single-component interventions, only four (intense self-management and transition coaching of high-risk patients and nurse home visits and telephone support of patients with heart failure) were effective in reducing readmissions. Multicomponent interventions that featured early assessment of discharge needs, enhanced patient (and caregiver) education and counselling, and early postdischarge follow-up of high-risk patients were associated with evidence of benefit, especially in populations of older patients and those with heart failure.Conclusion. Peridischarge interventions are highly heterogenous and reported outcomes show considerable variation. However, multicomponent interventions targeted at high-risk populations that include pre-and postdischarge elements seem to be more effective in reducing readmissions than most single-component interventions, which do not span the hospitalcommunity interface.What is known about this topic? Unplanned readmissions within 30 days of hospital discharge are common and may reflect deficiencies in discharge processes. Various peridischarge interventions have been evaluated, mostly single-component interventions that occur either before or after discharge, but failing to yield consistent evidence of benefit in reducing readmissions. More recent trials have assessed multicomponent interventions which involve pre-and postdischarge periods, but no formal review of such studies has been undertaken. What does this paper add? With the exception of intense self-management and transition coaching of high-risk patients, and nurse home visits and telephonic support for patients with heart failure, single-component interventions were ineffective in reducing readmissions. Multicomponent interventions demonstrated evidence of benefit in reducing readmissions by as much as 28%, with best results achieved in populations of older patients and those with heart failure. What are the implications for practitioners and managers? Hospital clinicians and managers should critically review and, where appropriate, modify their current discharge processes in accordance with these findings and negotiate the extra funding and personnel required to allow succ...

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“…The effect of the ICM approach may therefore have been influenced or strengthened by the use of the best available evidence relating care needs to care provision. For example, the COPD review noted the use of protocols in some studies (Rabow et al, 2003) or the MDT reviews noted that, most often, multidisciplinary teams were a component of the program or strategy (Brand et al, 2004).…”

Section: Narrative Summary Of Common Findings From Individual Reviewsmentioning

confidence: 99%

“…Even though the individual review topics dealt with single interventions illustrating an ICM approach, most interventions were multicomponent (Crotty et al, 2004;Beland et al, 2006;Rabow et al, 2003;Brand et al, 2004). For example, care planning approaches often used standardised tools, case conferencing, case management and a multidisciplinary team.…”

Section: Narrative Summary Of Common Findings From Individual Reviewsmentioning

confidence: 99%

Integration, Coordination and Multidisciplinary Care: What can These Approaches Offer to Australian Primary Health Care?

Tieman¹,

Mitchell²,

Shelby‐James³

et al. 2007

Aust. J. Prim. Health

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A transitional care service for elderly chronic disease patients at risk of readmission

Cited by 41 publications

References 22 publications

Local trends in emergency department attendances by older patients in an ageing national population

Local trends in emergency department attendances by older patients in an ageing national population

Preventing the rebound: improving care transition in hospital discharge processes

Integration, Coordination and Multidisciplinary Care: What can These Approaches Offer to Australian Primary Health Care?

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