Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

Naylor, Mary D.; Brooten, Dorothy; Campbell, Roberta; Maislin, Greg; McCauley, Kathleen M.; Schwartz, J. Sanford

doi:10.1111/j.1532-5415.2004.52202.x

Cited by 1,138 publications

(1,268 citation statements)

References 35 publications

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“…2 They are more likely to be non-English speakers, 3 have lower health literacy, which can impair selfmanagement; [4][5][6] higher rates of mental health and substance abuse disorders; 7 greater exposure to social stressors; 6 and are more likely to experience hospital readmission. [8][9][10] Several care transitions programs [11][12][13][14][15][16] have demonstrated success in decreasing hospital readmissions. These programs have primarily targeted elderly Medicare populations or patients with high risk diagnoses, such as heart failure.…”

Section: Introductionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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BACKGROUND: Evidence-based interventions to reduce hospital readmissions may not generalize to resourceconstrained safety-net hospitals. OBJECTIVE: To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN: Randomized controlled trial. PARTICIPANTS: General medicine inpatients having at least one of the following readmission risk factors: (1) age≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS: PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES: The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS: Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS: A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.KEY WORDS: care transitions; continuity of care; health care delivery; patient safety; underserved populations. J Gen Intern Med 30(7):907-15

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Section: Introductionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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“…Yet, to date, no single intervention has reliably reduced 30-day readmission rates. 4 Interventions are often disease-specific, [5][6][7][8] require substantial financial investments in training allied healthcare professionals, 6,9,10 or focus primarily on hospital-based discharge planning with mixed results. 4,[11][12][13] Additionally, interventions are often multifaceted, and it is difficult to identify which elements drive improvements in patient outcomes.…”

Section: The Challenge Of Ensuring Optimal Care During Transitionsmentioning

confidence: 99%

Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs

et al. 2014

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With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.

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“…69 Care transitions are an active area of research, and multiple studies have shown lower rates of rehospitalization with comprehensive transitional care programs involving ''transition coaches'' or advance practice nurses providing home visits and follow-up telephone calls. 70,71 More research is needed in this area to develop simple, cost-effective care transitions programs. In the meantime, hospitalists can actively involve a multidisciplinary team (pharmacists and social workers, for example) early in the hospitalization, provide more ''patient-friendly'' discharge materials such as those available as part of the Society of Hospital Medicine's BOOST, and place targeted follow-up phone calls after discharge.…”

Section: Discharge Planning For An Elderly Patient Should Start Earlymentioning

confidence: 99%

Ten ways to improve the care of elderly patients in the hospital

Labella

Merel

Phelan

2011

Journal of Hospital Medicine

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Hospitalists care for elderly patients daily, but few have specialized training in geriatric medicine. Elderly patients, and in particular the very old and the frail elderly, are at high risk of functional decline and iatrogenic complications during hospitalization. Other challenges in caring for this patient population include dosing medications safely, preventing delirium and accidental falls, and providing adequate pain control. Ways to improve the care of the hospitalized elderly patient include the following: screening for geriatric syndromes such as delirium, assessing functional status and maintaining mobility, and implementation of interventions that have been shown to prevent delirium, accidental falls, and acute functional decline in the hospital. This article addresses these issues with 10 evidence‐based pearls developed to help hospitalists provide optimal care for this expanding population. Journal of Hospital Medicine 2011;6:351–357. © 2011 Society of Hospital Medicine

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Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

Cited by 1,138 publications

References 35 publications

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs

Ten ways to improve the care of elderly patients in the hospital

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