Preventing 30-day rehospitalization among elderly patients through a collaborative transition of care program between acute and primary care.

摘要

There is a disconnect between acute and primary care when transitioning elderly patients from the hospital to the community, often leading to insufficient primary care follow-up and increased rehospitalization. The purpose of this pilot study was to examine the effect of a multi-component transition of care intervention coordinated by the primary care setting on 30-day rehospitalization and primary-care follow-up rates, as well as to examine the implementation of the intervention into practice. Thirty-day outcomes were measured by telephone interview and electronic record review of 10 elderly participants who were discharged from a local hospital and received the multi-component transition of care intervention led by an adult-gerontological primary care nurse practitioner. Of the 10 participants who completed all phases of the intervention and lived to 30-days post-discharge, none had a 30-day rehospitalization. The intervention may be effective in preventing 30-day rehospitalization. Completing post-hospital follow-up appointments was more efficient than those completed prior to implementation because the nurse practitioner had already met with participants during their hospital stay to gather information on the hospitalization and begin discharge planning. The intervention required a proactive approach from the primary care office to obtain hospitalization information, and was found to be time intensive, yet effective, among this group of participants. Further research is needed with a larger sample size and a longer duration of follow-up.