Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital

Abstract

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively low amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.

Preventing Hospitalizations in Children With Medical Complexity: A Systematic Review

“…Controlled studies of this intervention have revealed that combining postdischarge home visitation, selfcare, and health coaching activities for patients and caregivers has led to improvements in caregiver activation and self-management with reductions in cost and readmissions in the months after discharge. [45][46][47][48] Promising work that builds off the community health worker model 49 and nurse case management programs 50 have also led to reduced utilization after discharge. Refining and testing optimal home visit logistics, scope, and content as well as postdischarge activities are important next steps with the CMC population.…”

Transição Do Cuidado Do Hospital Para O Domicílio: Revisão Integrativa

“…Os enfermeiros realizam educação em saúde sob diversos aspectos: mudança na dieta e possíveis restrições de alimentos (27)(28)33,35) , realização de exercícios físicos (25,35) , uso correto das medicações, como dosagem, frequência de administração e horários (14,(17)(18)(19)(21)(22)(25)(26)(28)(29)(30)33) , interações dos medicamentos de uso contínuo (14,16,20,26,32,35) , reconhecimento de sinais e sintomas da doença em curso (19)(20)(22)(23)(25)(26)(27)(28)30,35) e autocuidado no domicílio (15,22,35) . Alguns enfermeiros realizam a reconciliação medicamentosa, avaliando medicamentos de uso anterior à internação com os prescritos no ambiente hospitalar (16,20,24) .…”

“…Alguns enfermeiros realizam a reconciliação medicamentosa, avaliando medicamentos de uso anterior à internação com os prescritos no ambiente hospitalar (16,20,24) . Outros utilizam apoio de encartes ilustrativos para reforçar orientações dos cuidados (25,26,28) e linguagem simples, além da utilização do feedback das informações para verificar a compreensão do paciente quanto às informações prestadas (19,30) .…”

“…Outro modo de articulação entre serviços é feito por meio de telefonemas dos enfermeiros hospitalares, para que o enfermeiro da atenção primária realize visita domiciliar e esclareça as dúvidas do paciente (26) . Também é utilizado o sistema informatizado do hospital, interligado à rede de saúde local.…”

A primary care physician's ideal transitions of care—where's the evidence?

“…Even though a 2006 Cochrane review did not find a positive impact of hospital-based postdischarge phone calls on readmission rates, 13 recent studies among select populations found small but significant reductions. 14,15 Others have looked at fulfilling this role in the outpatient setting. 16,17 A recent systematic review of primary care clinic-based postdischarge phone calls showed no impact on readmission rates, but only 3 studies were included.…”