Journal of Gerontological Nursing

Feature Article 

From Hospital to Home: A Brief Nurse Practitioner Intervention for Vulnerable Older Adults

Susan Enguidanos, PhD; Nancy Gibbs, MD; Paula Jamison, MA

Abstract

A randomized controlled trial was conducted to evaluate the impact of a brief nurse practitioner (NP) intervention on care transitions among older hospitalized adults discharged to home (N = 199). Immediately following discharge, participants randomly assigned to the intervention received up to three home visits and two telephone calls from a registered NP that included medication review, care coordination, assessment of medical care needs, and brief coaching in self-management skills. Usual care participants received all standard medical care, including access to case management services. Intervention participants reported improved satisfaction with medical care (p = 0.008) and self-efficacy in managing medical conditions (p = 0.001) and had fewer primary care visits (p = 0.036) but no change in hospital readmissions at 6 months following enrollment. These findings suggest that intervening at the point of transition may extend the reach of the primary care physician by improving patient outcomes through nursing support at a high-risk period of care—the transition from hospital to home.

Abstract

A randomized controlled trial was conducted to evaluate the impact of a brief nurse practitioner (NP) intervention on care transitions among older hospitalized adults discharged to home (N = 199). Immediately following discharge, participants randomly assigned to the intervention received up to three home visits and two telephone calls from a registered NP that included medication review, care coordination, assessment of medical care needs, and brief coaching in self-management skills. Usual care participants received all standard medical care, including access to case management services. Intervention participants reported improved satisfaction with medical care (p = 0.008) and self-efficacy in managing medical conditions (p = 0.001) and had fewer primary care visits (p = 0.036) but no change in hospital readmissions at 6 months following enrollment. These findings suggest that intervening at the point of transition may extend the reach of the primary care physician by improving patient outcomes through nursing support at a high-risk period of care—the transition from hospital to home.

Dr. Enguidanos is Hanson Family Trust Assistant Professor, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, Dr. Gibbs is Regional Geriatric Coordinating Physician, Kaiser Permanente, Pasadena, and Ms. Jamison is Improvement Advisor, Kaiser Permanente Downey Medical Center, Downey, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was funded by a Kaiser Permanente Innovation Award.

Address correspondence to Susan Enguidanos, PhD, Hanson Family Trust Assistant Professor, Leonard Davis School of Gerontology, University of Southern California, 3715 McClintock Avenue, Gero 228B, Los Angeles, CA 90089-0191; e-mail: enguidan@usc.edu.

Received: January 06, 2011
Accepted: November 15, 2011
Posted Online: February 01, 2012

Transitions between different care settings are common, particularly among older adults. For example, in 2004, of more than 12 million hospitalized older adults, 28% were discharged to another institutional setting and 14% were discharged to home health care (Agency for Healthcare Research and Quality, 2004). Nineteen percent of U.S. older adults discharged from the hospital to a skilled nursing facility are readmitted within 30 days (Coleman, 2003), and among Medicare recipients, nearly 20% have a readmission within 30 days of hospital discharge.

Literature Review

Transition between medical care settings is an area of increasing focus as mounting evidence reveals the elevated risk for errors, complications, and poor outcomes during the transitional care process. These risks include medication and medical errors; incomplete or erroneous information; poor preparation; conflicting advice; poor communication, including inadequate administrative communication; service duplication; inappropriate care; care inconsistent with patient preferences; and lack of follow-up care (Coleman, 2003; Coleman, Smith, Raha, & Min, 2005; Enguidanos & Brumley, 2005; McLeod, McMurray, Walker, Heckman, & Stolee, 2011; Moore, Wisnivesky, Williams, & McGinn, 2003; Morrison, Olson, Mertz, & Meier, 1995; Saliba et al., 2000; Sobel, Medina-Walpole, & Katz, 2004; Weaver, Perloff, & Waters, 1998). A recent study found that 94% of the older adult sample experienced one or more medication discrepancies, with an average of 3.3 discrepancies per participant (Corbett, Setter, Daratha, Neumiller, & Wood, 2010). Furthermore, inconsistent discharge planning and lack of family support to provide in-home patient care compound these issues (Magilvy & Congdon, 2000).

Poor transitions and the risks associated with them have a tremendous impact on the health care system, resulting in high rates of avoidable health care costs. Thirty-day readmissions among Medicare beneficiaries have been estimated to cost approximately $15 billion (Medicare Payment Advisory Commission, 2007), much of which is potentially avoidable. As the proportion of older adults grows and rates of chronic illness increase, models of care that reduce the use of high-cost acute care will become increasingly critical (Stone, Dawson, & Harahan, 2003). Moreover, the Patient Protection and Affordable Care Act of 2010 (PPACA) proposes to reduce reimbursement for hospital readmissions by 2012, thereby moving the fiscal responsibility for these preventable readmissions to many managed care providers, health plans, and hospitals. As this deadline encroaches, effective methods to improve transitional care are urgently needed.

Studies of older adults have found that many emergency department visits and hospitalizations could be shortened (Holland & Hemann, 2011) or avoided altogether if appropriate follow-up care were provided (Coleman, Min, Chomiak, & Kramer, 2004; Moore et al., 2003; van Walraven, Seth, Austin, & Laupacis, 2002). According to a 2007 Medicare Payment Advisory Commission report, approximately three quarters of readmissions could be prevented. However, a recent study of a social work-based intervention found that many of the problems patients encountered following hospital discharge could not have been anticipated or prevented by the discharge planner prior to discharge (Fabbre, Buffington, Altfeld, Shier, & Golden, 2011).

Additionally, studies testing the efficacy of a nurse transitional support service for older patients discharged from the hospital found significant cost savings among recipients of the intervention (Coleman, Parry, Chalmers, & Min, 2006; Naylor et al., 1999). Although these studies have demonstrated promising outcomes, they have not been widely replicated. This could be largely a result of financial barriers associated with adding multiple visits from a nurse practitioner (NP) and/or the overlap of the intervention with other medical services, such as discharge planning and home health care. This pilot study tested a brief transition intervention that reduced overlap with existing health services and utilized usual care services to enhance follow up. The study aimed to determine whether a Brief Nurse Practitioner Transition (BNPT) intervention conducted by an NP could improve patient satisfaction and self-efficacy in managing patient health and reduce medical service use among hospitalized older adults discharged to home who do not qualify for home health care services, hospice, or palliative care.

An NP paired with existing social work care management services provided a brief evaluation to identify patient needs, education, and training to patients managing their medical conditions and facilitated connection of patients with the care modality most appropriate to their conditions.

Method

A brief transition intervention for older adults was pilot tested using a randomized controlled trial conducted at a managed care medical center. Eligible patients were randomly assigned to either the intervention group (BNPT) or usual care.

The setting for this pilot study was a large, managed care medical center (HMO) that provides medical service to a multi-ethnic, multi-socioeconomic population in Los Angeles County, California. All participants were members of the HMO and received their medical care through the HMO, regardless of whether they were insured directly through the HMO or indirectly through Medicare. This study was approved by the Institutional Review Boards of both the clinical and community-based research agencies participating in the study.

Procedures

Discharge planners invited hospitalized patients meeting the following criteria to participate: age 50 or older; discharged to home (community setting) without home health, palliative care, or hospice care; and have either no caregiver in the home or a caregiver who was unable to provide the care needed to support the patient in the home (as determined by the discharge planner). The patient also had to meet one of the following criteria: (a) be taking more than seven medications; (b) have deficiency in one or more activity of daily living (ADL, e.g., feeding, transferring, toileting, dressing, bathing); or (c) have been previously admitted to the hospital within 30 days of the current admission. We selected these criteria to target at-risk older adults being discharged to home without formal in-home care (e.g., home health or hospice) or able and available caregivers—factors identified by this HMO’s discharge planners as most concerning when discharging frail older adults to home.

Discharge planners assessed patients for study eligibility through the use of a one-page screening tool. Eligible patients received an overview of the study from the discharge planner and were provided a study information sheet. After receiving patient consent to participate, the discharge planners selected the next consecutive envelope from a packet of numbered, sealed envelopes, each containing a pre-determined study group assignment unknown to the discharge planner.

BNPT Intervention

The BNPT intervention was developed using the Care Transitions Model (Parry, Coleman, Smith, Frank, & Kramer, 2003) and modified to target a high-risk population using existing medical care services (i.e., case managers) to support the transition intervention. Consistent with previous studies (Coleman et al., 2006; Naylor et al., 1999), an NP was selected to provide the intervention.

Discharge planners immediately notified the NP of the participants randomized to the intervention group, and the NP either made a home visit or telephoned the patient within 72 hours of discharge. The NP had no contact with the patient prior to hospital discharge. A checklist modified from an effective transition intervention (Coleman et al., 2006) was used to guide the NP in addressing the principal aims outlined above.

The NP provided one to three home visits with one to two follow-up telephone calls as needed. Individuals receiving two or more home visits were those at high medical risk or experiencing several potential complications. In an effort to build on current resources, the medical center’s senior case managers were given responsibility to provide telephone follow up and referrals consistent with problems identified by the NP, such as depression care, enrollment in disease management classes, referrals to in-home support services, and provision of advance directive forms. These case management activities were available to any medical center patient. Case managers primarily provided telephone guidance and resources to clients by linking them to medical, social, and community-based services as needed; this is standard procedure for all older adults referred to case management services.

The NP conducted the primary components of the intervention, core components found to be effective in previous transition intervention studies (Coleman et al., 2006; Naylor et al., 1999), including: (a) ensuring the participant understood discharge instructions and had questions and concerns addressed; (b) identifying potential medication errors and adherence issues and reconciling them; (c) assessing the participant’s needs and identifying resources, services, and programs; (d) empowering the participant to obtain identified services and assistance; (e) ensuring the participant had follow-up medical appointments scheduled; and (f) determining whether the participant was experiencing any difficulties in managing his or her health or medical symptoms that needed to be addressed (Figure).

Intervention activities checklist.Note. MR = medical record; PCP = primary care physician; KP = the managed care medical center; SCM = senior care management; TCM = telephone care management; HH = home health care; HO/PC = hospice/palliative care.

Figure. Intervention activities checklist.Note. MR = medical record; PCP = primary care physician; KP = the managed care medical center; SCM = senior care management; TCM = telephone care management; HH = home health care; HO/PC = hospice/palliative care.

The intervention provided a bridge from hospital discharge to the next primary care physician appointment to improved home support for implementing the care plan developed in the hospital. Coordination, support, and medication reconciliation were critical elements of this intervention, requiring the skills of the NP. The NP contacted the primary care physicians when potential medication problems were identified to notify them of patient physical and mental health issues (e.g., need for hospice or antidepressant agents). Referrals were provided to available medical center and community programs (e.g., exercise, falls prevention, disease-specific programs), as needed. Participants were the primary recipient of all interventions; however, the NP included family members, neighbors, and caregivers in the intervention when needed.

The NP conducted all assessments and training with the patients and families and developed the care plan, whereas the case managers primarily provided connection to resources as delineated in the care plan. The case managers did not receive additional training related to this project, but rather performed their standard telephone case management activities targeted to the problems identified by the NP.

Fidelity. Two mechanisms were used to maintain fidelity to the intervention model. First, the NP used a checklist at each client visit/contact to provide structure and record her intervention activities. Second, biweekly case reviews were held with the two co-principal investigators (S.E. and N.G.) where the intervention records were reviewed and cases discussed. Discussion of the cases was critical to the intervention to help the NP focus specifically on the intervention components rather than duplicate primary care efforts, such as providing a physical assessment or follow-up medical care in the home.

Usual Care

Participants enrolled in usual care received all medical services for which they were eligible, including disease and senior case management, home health (although participants did not receive home health at the time of hospital discharge), physician office visits, and emergency department and hospital use. The senior case management service was accessed directly by participants or family members or through referrals from discharge planners, physicians, or other health care providers. This service was provided via telephone and included provision of referrals to medical care and to home- and community-based services. The primary difference between this case management service and the NP intervention was that case management services were not provided immediately (i.e., the waiting period for care could range from 2 days to 2 weeks), care was provided via telephone, and the focus was largely to improve access to medical and community services, rather than address issues related to transitions in care (e.g., medication review, immediate scheduling of medical appointments). All intervention providers were blinded to the names and identities of patients assigned to the usual care group.

Data Collection

Eligibility data were collected by the discharge planners in the medical center. Baseline and follow-up data were collected by college-level research assistants blinded to study group assignment. Telephone interviews were conducted within 24 hours of hospital discharge and repeated 3 months later. Measures collected via telephone interview included self-efficacy in managing chronic conditions and satisfaction with medical care. Since reduction in hospital readmissions is the ultimate indication of the intervention’s cost effectiveness, study sample size was based on the results of a 1999 study by Naylor et al. With an alpha level of 0.05 and power level of 0.80, a total of 300 patients were needed after accounting for attrition.

Measures

Demographic Data. Demographic data, including ethnicity, age, sex, marital status, and living arrangement, were collected via telephone survey with the participant.

Patient-Perceived Efficacy in Self-Care and Management of Medical Conditions. The self-efficacy survey developed by Lorig, Sobel, Ritter, Laurent, and Hobbs (2001) was used to measure the self-efficacy of beliefs to perform specific behaviors, manage disease generally, and achieve outcomes. Test-retest reliability coefficients ranged from 0.82 to 0.89, and internal consistency co-efficients ranged from 0.77 to 0.92. The measure includes 14 items, each with a 10-point response set ranging from 1 (not at all confident) to 10 (totally confident). Sample questions ask how confident respondents are that they could obtain disease information, manage their illness, and get help with daily activities. Items are summed for an aggregate score ranging from 14 to 140, with higher scores indicating higher self-efficacy in performing these activities.

Patient Satisfaction with Care. Patient satisfaction with care was measured using an adapted version of the Home Care Satisfaction Measure (Geron et al., 2000), with adaptations made by the researcher who developed the original instrument. This scale measures patient satisfaction with his or her level of involvement in health care and decision making, information/education received, emotional support, coordination/continuity of care, problem solving, and overall quality. It has been found to be sensitive in measuring change in satisfaction with care (Weiner, Wayne, & Khatutsky, 2007) and has good test-retest reliability (range = 0.68 to 0.88) and high concurrent validity (range = 0.26 to 0.76). Individual items were coded on a scale of 0 (low) to 100 (high), summed, and divided by the total number of responses received (to account for skipped or missing data)—a scoring procedure used in the original version of this instrument (Geron et al., 2000).

Service Utilization. Service utilization variables included number of emergency department visits, number of hospital admissions, days spent in the hospital, and number of physician office visits, including primary and specialty care. Data were collected from the HMO electronic medical record database 6 months after study enrollment and did not include any medical service use that may have occurred outside of the HMO (accounting for approximately 3% of all service use).

Statistical Analysis

Descriptive data were used to describe the sample and each study group. Bivariate analysis included t tests, and chi-square tests were conducted to determine whether significant differences were present between the groups in demographic characteristics, self-efficacy, satisfaction with care, and service utilization. Given the skewed distribution of the medical service data, nonparametric tests were conducted to determine group differences.

Results

Sample

A total of 199 participants were enrolled in the BNPT study from July 2006 through June 2007. Of these, 100 were randomly assigned to the intervention group and 99 to usual care. Among those enrolled in the study, 67% were taking seven or more medications, 61% had one or more ADL deficiency, and 25% had been readmitted to the hospital in the previous 30 days. More than half (57.8%) met one of these study criteria, 30.2% met two, and 12.1% met all three.

Participants’ ages ranged from 50 to 97 (mean age = 73.58, SD = 10.53 years). Regarding race/ethnicity, 38.7% of participants were Caucasian, 21.6% were Latino, and 18.6% were African American (Table 1). Approximately half of participants were women (55.8%), and the majority were married (52.8%); approximately one quarter (26.6%) were widowed. More than half (54.2%) reported their annual income level at $20,000 or less; 78.4% reported living in their own home. The majority of participants lived with their spouses (48.2%) or with a child (21.1%). The mean number of medical conditions reported was 2.47 (SD = 1.28). No statistical differences were found in any of the demographic variables between study groups, verifying that randomization was successful in creating two equivalent groups (Table 1).

Description of the Sample

Table 1: Description of the Sample

Intervention Contacts

The NP recorded the number of contacts made, whether by telephone or in person. The majority of intervention participants (70.4%) received one in-home visit, with telephone follow up and referral as needed. The number of telephone contacts ranged from zero to four, with most (67.7%) receiving one to two calls. Overall, all intervention participants received at least one call or visit and no more than six total contacts from the NP. Nearly all (94%) received a home visit. Five participants refused, receiving telephone intervention only, and one person was referred to hospice care prior to the NP home visit, following review of that participant’s medical record and discussion with the primary care physician.

Total time spent directly providing patient care ranged from 10 minutes to 7 hours, with the average time spent with each patient being 2.5 hours (SD = 75 minutes). Approximately one fourth (n = 24) were referred to case management for follow up to connect them with community resources and/or completing advance directives. All visits involved the patient, and approximately one third (n = 35) of the cases required follow up and inclusion of family members, caregivers, or neighbors.

Self-Efficacy

Participants were asked to report on their confidence level in performing certain activities relating to their health, including gathering information about their disease; obtaining help from community, family, and friends; and managing their disease and symptoms. Baseline and follow-up surveys were available for 131 study participants. Within-group analysis of change in self-efficacy for each study group revealed no significant difference in change in self-efficacy for the usual care group from baseline (mean = 100, SD = 25.6) to follow up (mean = 106, SD = 27.8; t = 3.42, p = 0.08), whereas the intervention group reported significant improvement from baseline (mean = 90, SD = 28.1) to follow up (mean = 103, SD = 30.1; t = 1.77, p = 0.001). However, this difference in change was not significant in between-group analysis (t = 1.35, p = 0.18).

Satisfaction

Baseline and follow-up surveys were available for 141 study participants. Analysis of scores from baseline to 3 months by study group revealed a significant improvement in satisfaction among those enrolled in the intervention (mean = 74.78, SD = 19.6 versus mean = 81.77, SD = 18.7; p = 0.008, effect size = −0.18), whereas the level of satisfaction among those receiving usual care was statistically unchanged (mean = 74.55, SD = 21.5 versus mean = 77.17, SD = 18.8; p = 0.346, effect size = 0.07).

6-Month Service Utilization Data

This study examined the impact of the intervention on service utilization for the 6 months following study enrollment (n = 195). Service utilization data included the number of emergency department visits, physician office visits, hospital days, and home health care visits. Those assigned to the intervention group had significantly fewer physician office visits (mean = 9.94, SD = 8.5 versus mean = 11.72, SD = 7.7; p = 0.036) and approximately half as many emergency department visits (mean = 0.50, SD = 1.2 versus mean = 0.99, SD = 2.5; p = 0.096) compared with the usual care group, although the difference was not statistically significant. No differences were found in days spent in the hospital (p = 0.514) or home health care days of service (p = 0.485; Table 2).

Mean Comparison of Medical Service Utilization at 6 Months

Table 2: Mean Comparison of Medical Service Utilization at 6 Months

Discussion

Evidence that Supports Replication

This study illuminates several important findings that relate to key health care policy changes. First, the findings suggest that significant results in improved satisfaction may be achieved through a brief intervention consisting of one to two home visits, telephone follow-up support, and case management provision of links to community and medical services. Additionally, although significant differences were not found in rates of change in self-efficacy, within-group improvement was found for those in the intervention group. These findings suggest that using a NP at the point of transition may extend the reach of the primary care physician in enhancing patient outcomes through improved nursing support at a high-risk period (i.e., the transition from hospital to home). The nurse and the case management follow up provide timely training, coaching, and support that empower patients to seek needed medical care and community services. These resources may improve their self-efficacy in managing chronic conditions, which may be key to reducing emergency department visits.

A primary component of this intervention was ensuring participants reconnected with their primary care physician; this involved the NP determining whether a follow-up appointment had been scheduled with the physician, helping participants set up this appointment, and facilitating access to primary care when participants experienced difficulty securing an appointment within 2 weeks of hospital discharge. This reconnection with primary care, plus the nurse home support, may have avoided exacerbation of conditions, thus decreasing excessive use of primary and specialty care (approximately 10 visits in 6 months versus approximately 12 visits in 6 months for the usual care group). More research is needed to better understand the impact of this program goal on actual physician office appointments.

Baseline data suggest that intervention group participants may have been less able to manage their health conditions, as demonstrated by the higher rate of readmissions at enrollment (30% versus 20% for usual care) and lower levels of self-efficacy at baseline. Follow-up self-efficacy scores were similar for both groups, perhaps influenced by the comprehensive HMO medical system response to the medical needs of training for patients, which may include disease-specific and general case management as well as specialty and primary care. While both the intervention and usual care groups showed increased self-efficacy at follow up, significant improvement was noted for the intervention group.

The eligibility criteria specifically targeted older adults who did not meet criteria for other home-based medical care, such as home health or hospice services, and aimed to reduce service overlap between hospital care and discharge planners. The PPACA (2010) specifies that transitional care models should begin no earlier than 24 hours prior to hospital discharge and not overlap with discharge planning activities. The initiation of this brief NP intervention at the time of discharge did not appear to disrupt the transition from hospital to home. Additionally, given the challenges to determine timing of pending discharges, initiating a transition service at the point of discharge may be the most efficient method of reducing overlap of care and ensuring the provision of transitional care to those discharged to home.

Evidence that Suggests a Need for Modifications

Several findings related to this trial support the need for a modified approach to transitional care. While the reduced overlap between transition NP and discharge planner prior to discharge did not appear to negatively affect the intervention, the aim of decreasing overlap between home health care and transition NP proved challenging in several ways. A key problem arose in terms of screening and study enrollment. Discharge planners often were unaware of the planned discharge disposition among the older participants. They were unsure whether a patient would be discharged to a nursing facility, home with home health care, or home with no in-home care—making it difficult for discharge planners to determine study eligibility until the hours immediately prior to discharge. As a result, many patients were discharged without being screened for study eligibility. This is an important factor for hospitals considering transition programs; many model programs target high-risk patients, thus relying on screening of patient populations. Hospitals need to develop plans to ensure that screening is feasible in a timely manner, and if not, identify strategies to enable a timely screening process.

While study participants did not have home health care ordered at the time of hospital discharge, half (50%) of those enrolled in the study eventually received such care during the 6 months following study enrollment. Thus, reducing duplication between transitional care services and home health care is extremely challenging and may be unavoidable. This may not be an issue, however, because a previous study found that receipt of home health care does not influence outcomes of transition models (Naylor et al., 2004).

Finally, given the scope of work for transition NPs and the challenges associated with limiting their scope of practice for this intervention, an RN may be a better fit for the intervention and a more cost-effective route for providing care.

Limitations

This study is limited in several ways. A primary limitation was the small sample obtained in the pilot. While the researchers originally sought to enroll 300 patients, challenges encountered in the screening and enrollment processes by the discharge planners led to the enrollment of only 199 participants. Specifically, discharge planners had little lead time or preparation prior to patient discharge, and both patients and discharge planners were often unaware of discharge plans until very shortly before discharge. This may have reduced the ability to achieve sufficient power to obtain clinical and statistical significance in service use measures. In addition, the subsequent small sample may have contributed to the lack of significant difference in both emergency department visits and hospitalizations. Attrition on follow-up surveys also limits the power in detecting between-group differences, with approximately a 65% response rate to the follow-up survey.

Furthermore, medical service utilization data only included those data from within the HMO system and did not include utilization that occurred outside the organization. Outside service use data were not available for both study groups but generally represent only 3% of total medical service among members of this managed care organization, according to managed care billing services. Moreover, medical service utilization data did not include information on the use of case management services; therefore, we were unable to determine the portion of both intervention and usual care patients receiving case management services. Finally, this study used one NP; thus, the findings may be influenced to some extent by practitioner variables. Actual visit times were not recorded, so data on mean time from discharge to NP visit are unavailable.

Recommendations

Despite these limitations, this pilot study provides findings consistent with other transitions studies, particularly in terms of patient-reported outcomes. A transition study following congestive heart failure patients for 4 months post-hospital discharge (Naylor et al., 2004) found that compared with usual care patients, intervention participants demonstrated improvement in patient satisfaction at 2 weeks and lower readmission rates at 1 year. Likewise, Coleman et al. (2006) found similar trends in their transitions coaching intervention that followed hospitalized patients for 24 days post discharge. Those receiving the intervention had fewer readmissions at 90 and 180 days following discharge, and intervention patients reported higher levels of knowledge and confidence in their ability to manage their illness and take their medications. Conversely, the current study targeted a population that may have been more frail with less family and caregiver support than those targeted in other transition interventions. While previous studies used eligibility criteria largely focused on age (older than 65 or 70) and the presence of one defined chronic condition (Coleman et al., 2006; Naylor et al., 2004), this study targeted individuals with additional risks, including having seven or more prescription medications, an ADL deficiency, and/or a rehospitalization within the previous 30 days.

Further studies with larger samples are needed to determine whether the findings reported here are supported, as well as to better understand the myriad needs of this high-risk population.

Clinical Implications

This study has several important implications for clinical practice. First, the data from this study demonstrate the challenges in identifying and targeting high-risk patients at the time of discharge. Better mechanisms may be needed, such as the development of electronic targeting systems, to avoid relying on nursing staff who may be too burdened to adequately screen and identify high-risk patients. Moreover, data from this and previous studies suggest that providing a transition service that complements rather than overlaps other medical care, such as Medicare-certified home health care, is difficult and may not be duplicative. Despite the challenges encountered, data from this small pilot suggest that a brief targeted intervention, with support from case managers, may be effective in improving patients’ experience with care and their ability to better manage their medical conditions. However, additional studies are needed to confirm these findings.

Conclusion

The targeted and brief nature of the BNPT intervention offers an innovative and replicable approach to reducing risks at transition between care settings among patients who are discharged to home and who do not qualify for home health care services, hospice, or palliative care. Significant improvements were found in the intervention group, with the majority (70.4%) of patients receiving only one home visit. Further research is needed to better understand the extent of benefits to be gained by vulnerable older adults transitioning from hospital to community using brief interventions aimed at easing the transition and reconnecting patients to community and medical services.

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Description of the Sample

Entire Sample (N = 199) Intervention Group (n = 100) Usual Care Group (n = 99)
Variable n(%) n(%) n(%) pValue*
Sex 0.179
  Women 111 (55.8) 61 (61) 50 (50.5)
  Men 84 (42.2) 38 (38) 46 (46.5)
  Unknown 4 (2) 1 (1) 3 (3)
Race/ethnicity 0.612
  Caucasian 77 (38.7) 40 (40) 37 (37.4)
  Latino 43 (21.6) 23 (23) 20 (20.2)
  African American 37 (18.6) 16 (16) 21 (21.2)
  Asian/Pacific Islander 14 (7) 7 (7) 7 (7.1)
  Other/Unknown 28 (14) 14 (14) 14 (14.1)
Marital status 0.757
  Married 105 (52.8) 54 (54) 51 (51.5)
  Widowed 53 (26.6) 28 (28) 25 (25.3)
  Divorced/single 27 (13.6) 11 (11) 16 (16.2)
  Unknown 14 (7) 7 (7) 7 (7.1)
Living situation 0.597
  With spouse 96 (48.2) 50 (50) 46 (46.5)
  With child 42 (21.1) 22 (22) 20 (20.2)
  Alone 35 (17.6) 17 (17) 18 (18.2)
  Other/Unknown 26 (13.1) 11 (11) 15 (15.2)
Income 0.787
  < $20,000 74 (37.2) 39 (39) 35 (35.4)
  $20,000 to $39,999 45 (22.6) 25 (25) 20 (20.2)
  ⩾ $40,000 22 (11.1) 11 (11) 11 (11.1)
  Unknown 58 (29.1) 25 (25) 33 (33.3)
Baseline 30-day readmission rate (n = 171a) 50 (29.2) 30 (33) 20 (25) 0.253
Mean (SD) Mean (SD) Mean (SD) pValue
Age (years) (N = 199) 73.58 (10.53) 74.38 (10.01) 72.78 (11.03) 0.284
Number of medical conditions (n = 176) 2.47 (1.28) 2.40 (1.40) 2.53 (1.15) 0.515
Self-efficacy (baseline) (n = 164) 94.0 (28.5) 89.9 (29.1) 98.1 (27.5) 0.067
Satisfaction with care (baseline) (n = 169) 73.2 (21.0) 73.38 (19.7) 73.02 (22.3) 0.912

Mean Comparison of Medical Service Utilization at 6 Months

Intervention Group Usual Care Group
Medical Service Mean (SD), Range Mean (SD), Range pValuea Effect Size Correlation
Physician office visits 9.94 (8.5), 0 to 47 11.72 (7.7), 0 to 32 0.036 0.11
Emergency department visits 0.50 (1.2), 0 to 10 0.99 (2.5), 0 to 15 0.096 0.12
Hospital days 3.78 (8.8), 0 to 67 3.49 (6.5), 0 to 44 0.514 −0.02
Home health days 4.99 (8.7), 0 to 41 5.57 (9.3), 0 to 54 0.485 0.03
Hospital readmission rateb 40% 44.4% 0.526

Keypoints

Enguidanos, S., Gibbs, N. & Jamison, P. (2012). From Hospital to Home: A Brief Nurse Practitioner Intervention for Vulnerable Older Adults. Journal of Gerontological Nursing, 38(3), 40–50.

  1. Use of a brief nurse practitioner (NP) intervention at the transition from hospital to home may be effective in improving older patients’ experience with care and their ability to better manage their medical conditions.

  2. An NP visit and telephone follow up post hospital discharge may extend the reach of the primary care physician.

  3. Further research is needed to determine better mechanisms for targeting older adults at high risk for hospital readmission.

Authors

Dr. Enguidanos is Hanson Family Trust Assistant Professor, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, Dr. Gibbs is Regional Geriatric Coordinating Physician, Kaiser Permanente, Pasadena, and Ms. Jamison is Improvement Advisor, Kaiser Permanente Downey Medical Center, Downey, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was funded by a Kaiser Permanente Innovation Award.

Address correspondence to Susan Enguidanos, PhD, Hanson Family Trust Assistant Professor, Leonard Davis School of Gerontology, University of Southern California, 3715 McClintock Avenue, Gero 228B, Los Angeles, CA 90089-0191; e-mail: .enguidan@usc.edu

10.3928/00989134-20120116-01

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