To the Hospital and Back Home Again: A Nurse Practitioner-Based Transitional Care Program for Hospitalized Homebound People

Abstract

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission

“…3 Net costs rose in 4 studies: both readmissions and costs climbed in 1 study, 71 while costs per hospitalization rose in 3 studies, including 1 among surgical patients. [72][73][74] See eTable 7 in the Supplement for data used to standardize costs.…”

“…[6][7][8][9][10][11][12][13][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] Twenty-one studies applied to general populations, largely older adults and together included 10 445 patients. 1,[57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74] Four studies applied to unique populations. 2,3,75,76 Twenty-nine studies were based in the United States, while the rest were in other nations.…”

Nonmedical factors associated with prolonged hospital length of stay in an urban homebound population

“…Thirty-six percent of patients in the program are hospitalized at least once per year while they are under the MSVD's care. 14 Patients in the MSVD are referred by their primary care physician to outpatient social work as needed for finite interventions, though not for ongoing case management; approximately one-third of all MSVD patients have been seen by an MSVD social worker over a 1-year period. 14 All patients enrolled in MSVD discharged from The Mount Sinai Hospital in New York from January 1, 2007, to December 31, 2007, were evaluated for inclusion in this study.…”

“…14 Patients in the MSVD are referred by their primary care physician to outpatient social work as needed for finite interventions, though not for ongoing case management; approximately one-third of all MSVD patients have been seen by an MSVD social worker over a 1-year period. 14 All patients enrolled in MSVD discharged from The Mount Sinai Hospital in New York from January 1, 2007, to December 31, 2007, were evaluated for inclusion in this study. The MSVD clinical database was cross-referenced with The Mount Sinai Hospital data system to maximize reliability of recorded admission and discharge dates.…”

The Effectiveness of a Care Transitions and Rapid Response Nurse Intervention at Reducing Readmissions and Emergency Department Use for High Risk Patients

“…While few trials have focused specifically on highly frail patients, in a mixed method study using a pre-post design, Ornstein et al [40] applied a care transition intervention to a patient population that included patients with cognitive impairment, that were generally older with an average age of 81 years, more frail, requiring assistance with five or more activities of daily living and utilizing more than 8.2 medications. The intervention did not demonstrate a reduction in hospital readmissions or costs [40].…”