Comprehensive discharge planning and home follow-up of hospitalized elders

Citation Naylor, M., Brooten, D., Campell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. v., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American Medical Association, 281 (7), 613-620.

Design Experiment.

Purpose The purpose of this experiment was to examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow up intervention for elders at risk for hospital readmissions.

Hypothesis It was hypothesized that the advance practice nurse-centered intervention will improve patient depression, increase patient satisfaction and reduce costs associated with repeated readmissions following initial discharge.

Participants Participants were patients of two urban hospitals in Philadelphia, PA. N= 363 (n=186 in the control group and n=177 in the intervention group).

Outcome / Dependent Variables The dependent variables in this study were readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction.

Procedure Participants in the treatment group received comprehensive discharge planning and home follow up at 2, 6, 12, and 24 weeks after hospital discharge by advanced practice nurses.

Outcomes The advanced practice nurse-centered discharge planning and home care intervention for at risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. The intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for re-hospitalization while reducing costs.

Author Naylor, M., Brooten, D., Campell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. v., & Schwartz, J. S.