Can transitional home care reduce repeat hospitalizations and costs among patients with congestive heart failure?

Elderly patients hospitalized for heart failure were less likely to be readmitted to the hospital or to die and had lower health care costs overall when they received transitional care from an advanced practice nurse who provided needs assessment, care planning, patient education, and therapeutic support through discharge planning and home follow-up visits.

Why is this important?

Older adults with multiple chronic health conditions and complex medication regimens are at high risk for poor outcomes following discharge from the hospital, which often leads to hospital readmission (Naylor 2002). Elders suffering from congestive heart failure—a life-threatening condition in which the heart cannot pump enough blood to meet the body's oxygen needs—have the highest rate of rehospitalization among adult patients (AHA 2005).

Interventions

Elderly patients ages 65 and older who were hospitalized with heart failure at one of six Philadelphia area hospitals during 1997 to 2001 were randomly assigned to receive either a transitional care intervention (the Quality-Cost Model of Advanced Practice Nursing Transitional Care) delivered by specially trained advanced practice nurses (APNs) or usual care.

Guided by a flexible, evidence-based protocol, the APNs collaborated with physicians to provide individualized needs assessment, care planning, patient education, and therapeutic support during the patient's hospitalization and in a series of home visits for three months after discharge. APNs were available seven days a week for telephonic patient support (Naylor et al. 2004).

Findings

At one year after hospital discharge, patients who received the transitional care intervention were less likely to have been readmitted to the hospital or to have died; also, they had 36 percent fewer hospital readmissions than patients who received usual care. The total cost of care for the intervention group was $4,845 (39%) lower per patient than for the usual care group, after accounting for the cost of the intervention (Naylor et al. 2004).

Implications

The authors attributed the success of this intervention to increased continuity of care and the individualized, holistic approach that APNs took to address patients' complex care needs.

A meta-analysis of 18 other randomized controlled trials found that comprehensive discharge planning plus post-discharge support (of varying intensity) for patients with heart failure reduced hospital readmissions by 25 percent on average (Phillips et al. 2004). Implementing such a program nationally for all Medicare beneficiaries could prevent up to 84,000 hospital readmissions each year.

Improvement Ideas and Resources

For more information, visit the Web site of the University of Pennsylvania's Hartford Center of Geriatric Nursing Excellence.

Measure:

This randomized controlled trial included 239 eligible patients ages 65 and older who were admitted from their homes to one of six Philadelphia academic and community hospitals between Feb. 1997 and Jan. 2001 with a diagnosis of heart failure. To be included, patients had to speak English, be alert and oriented, be reachable by telephone after discharge, and reside within 60 miles of the hospital. Patients with end-stage renal disease were excluded because of their unique service needs. Research assistants blinded to study assignment interviewed patients in the hospital to obtain baseline information and conducted telephone interviews at two, six, 12, 26, and 52 weeks after discharge to collect information on resource use, functional status, quality of life, and patient satisfaction. Resource costs were estimated using standardized Medicare reimbursement rates; intervention costs were calculated based on clinicians' billable time devoted to intervention related efforts. All differences between the intervention and control groups shown in the chart were statistically significant. In multivariate analysis, the time to first rehospitalization or death was significantly longer for patients in the intervention group. Efficacy did not vary by hospital although the intervention effect decreased over time. Only short-term improvements were seen in quality of life and patient satisfaction (Naylor et al. 2004).

Source:

The study used medical records and patient interviews and was conducted by researchers at the University of Pennsylvania and at Florida International University (Naylor et al. 2004).

References:

* Indicates source of data used in the chart(s).AHA (American Heart Association). 2005. Heart Disease and Stroke Statistics, 2005 Update. Dallas, Tex.: American Heart Association.

Naylor, M. D. 2002. Transitional Care of Older Adults. Annual Review of Nursing Research 20: 127–47.

* Naylor, M. D., D. A. Brooten, R. L. Campbell et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52 (5): 675–84.

Phillips, C. O., S. M. Wright, D. E. Kern et al. 2004. Comprehensive Discharge Planning with Postdischarge Support for Older Patients with Congestive Heart Failure: A Meta-Analysis. Journal of the American Medical Association 291 (11): 1358–67.