Follow-up care can reduce hospital readmission rate, cost

Elderly patients at high risk for poor outcomes after hospital discharge who received comprehensive discharge planning and home follow-up implemented by advanced practice nurses were hospitalized less often, less quickly, and at far less Medicare cost.

These were the findings of a study recently published in the Journal of the American Medical Association by Dorothy Brooten, dean of CWRU's Frances Payne Bolton School of Nursing, and Mary Naylor, associate professor of nursing at the University of Pennsylvania. The National Institutes of Health's National Institute for Nursing Research (NINR) funded the four-year study for more than $1.2 million.

"Discharge planning is often not tailored to individual patient needs," Brooten said. "In addition, home follow-up by advanced practice nurses familiar with the patient's past progress has made a significant difference in this study and others where we have applied the same approach."

In 1980, Brooten developed a pioneering transitional care model that has demonstrated significant reductions in health care costs for high-risk, high-cost patients. The model was the basis for the recent NIH study. Advanced practice nurses with master's degrees provide comprehensive discharge plans and home follow-up and are routinely on call for patients. The patients' physicians back the nurses.

When Brooten created the model, hospitals were beginning to discharge patients earlier to help reduce costs, and no one was assessing whether patients were being rehospitalized, how quickly rehospitalization was occurring, and at what cost, she said.

"Some vulnerable groups of patients like the elderly were falling through the cracks with managed care," Brooten said. "The costs of rehospitalization were prohibitive, and the quality of patient care was a concern."

Brooten's transitional care model provided continuity of care for vulnerable groups by matching advanced practice nurses who had specialized skills in working with

Contact: Kathleen McDermott
Case Western Reserve University

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