Journal of Gerontological Nursing

Feature Article 

Characteristics of Older Adults Rehospitalized Within 7 and 30 Days of Discharge: Implications for Nursing Practice

Debra J. Hain, PhD, APRN, GNP-BC; Ruth Tappen, EdD, RN, FAAN; Sanya Diaz, MD; Joseph G. Ouslander, MD

Abstract

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.

Abstract

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.

Potentially avoidable rehospitalizations consume a significant portion of health care costs. Approximately 20% of hospitalized Medicare beneficiaries are rehospitalized within 30 days of discharge (Jencks, Williams, & Coleman, 2009) at an estimated cost of approximately $12 billion per year (Medicare Payment Advisory Commission [MedPAC], 2008). To address concerns regarding the increasing numbers of older adults who are rehospitalized within 30 days of discharge, the Center for Medicare & Medicaid Services (CMS) identified 30-day rehospitalization rates as a major quality indicator for a 3-year scope of work for the Medicare Quality Improvement Organization (QIO) program.

Failure of the current Medicare fee-for-service payment system to control costs has led to the MedPAC (2008) endorsement of bundling payments under Medicare. This would involve one payment to multiple providers for the index (i.e., initial) hospitalization and a period of post-acute care that may be defined as 30 days after discharge (Hackbarth, Reischauer, & Mutti, 2008) The recommendations “are intended to create collective accountability across providers for selected episodes, such as those for congestive heart failure, chronic obstructive pulmonary disease, and cardiac bypass surgery” (Hackbarth et al., 2008, p. 3). Effective interventions aimed at reducing rehospitalizations of older adults are needed to help decrease health care costs (Jiang, Russo, & Barrett, 2009).

As payment for health care is transformed, hospitals will be forced to rethink current services and develop cost-effective, innovative programs aimed at reducing rehospitalizations. Many rehospitalizations could be avoided by improving coordination of care during the transition from one health care setting to another (National Transitions of Care Coalition [NTOCC], 2008), a time when older adults may be more vulnerable to postacute-care complications (Coleman, Min, Chomiak, & Kramer, 2004; Forster, Murff, Peterson, Gandhi, & Bates, 2003; Naylor et al., 2009).

Study Purpose

As members of interdisciplinary teams, nurses—advanced practice nurses (APNs), RNs, and licensed practical nurses (LPNs)—play an essential role in providing care during transitions. Currently, the hospital in this study has a case management team that assesses needs and then implements appropriate discharge strategies while the person is hospitalized. Post-hospital follow up involves a telephone interview using a patient satisfaction survey. Although important, this type of follow up has many limitations and may not identify those who are most vulnerable for 30-day rehospitalization. Preliminary data on rehospitalization rates and the characteristics of older adults who are rehospitalized within 0 to 7 days and 8 to 30 days may provide direction for targeting those at highest risk for rehospitalization and for designing new strategies to reduce rehospitalizations.

The purpose of this study was to:

  • Examine the rehospitalization rates and principal rehospitalization diagnoses of Medicare fee-for-service patients 75 and older by discharge location (home with self-care, home with home health care, and skilled nursing facility).
  • Compare index admission characteristics of Medicare fee-for-service patients 75 and older who were rehospitalized within 30 days and those who were not rehospitalized.
  • Compare the characteristics of Medicare fee-for-service patients 75 and older who were rehospitalized within 0 to 7 and 8 to 30 days of discharge.

Transitions of care can be considered a “component of the broader concept of care coordination” and is defined as a “set of actions designed to ensure the coordination and continuity, which includes a comprehensive plan of care and availability of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status” (NTOCC, 2008, p. 2). Emphasis will be placed on information that informs nursing interventions aimed at preventing potentially avoidable rehospitalizations of older adults discharged from community hospitals.

Method

This project is the first phase of a two-phase project aimed at reducing the rate of older adult rehospitalizations within 30 days of discharge. The second phase of this project involved the identification of all discharges of Medicare patients 75 and older over a 5-month period and implementing an RN-guided home health intervention aimed at improving health outcomes, such as reducing 30-day rehospitalizations. This article reports the findings from Phase 1.

Sample

Data on rehospitalizations of all Medicare fee-for-service patients 75 and older over a 12-month period (June 1, 2007 to May 31, 2008) were obtained from the information technology department of a 400-bed not-for-profit community hospital located in southeast Florida. Patients enrolled in Medicare-managed care programs were excluded from the analysis. The decision to include patients 75 and older was based on the belief that this population may be most vulnerable to 30-day rehospitalization. If a patient had more than one index (i.e., initial) admission during the study period, only data from the first index admission were included. The study was reviewed and approved by the hospital Institutional Review Board, and informed consent was waived.

Data Collection

Data were organized by index admission diagnosis and rehospitalization rates. For the purpose of this analysis, the number of days between the index admission and first rehospitalization (readmitted to study hospital after being discharged from this location), if any, were calculated. Principal and secondary diagnoses were determined by the hospital coders for the purpose of billing for diagnosis-related groups (DRGs). To examine the patterns of diagnoses at index admission and rehospitalization, two physician co-authors (J.G.O. and S.D.) categorized the diagnoses using basic diagnostic categories and specific DRGs. An attempt was made to place as many DRGs into one of the diagnostic categories; this was done so the number of index admission and rehospitalization diagnostic categories could be kept at a minimum. Other diagnoses that did not fit into diagnostic categories were placed in a category of “other.” Rehospitalization rate was defined as the number of patients rehospitalized divided by the number of patients who were discharged from the same facility. We calculated the rehospitalization rates for each initial discharge location and for three time periods, within 0 to 7, 8 to 30, and 0 to 30 days of initial discharge.

Data Analysis

Descriptive statistics were used to compare index admission characteristics of those who were rehospitalized and those who were not. The same comparison was done between patients who were rehospitalized within a week versus patients rehospitalized between 8 to 30 days post-discharge. Data were entered into the SAS version 9.2. Chi-square and one-way analysis of variance were used to compare index admission characteristics of those rehospitalized and those who were not; index admission characteristics of patients by discharge location; and principal rehospitalization diagnosis by initial discharge location.

Results

A total of 6,809 Medicare fee-for-service patients 75 and older were discharged during the study period (Figure). Overall, 12% (n = 792) of these patients were rehospitalized within 30 days of discharge. Discharge locations included home with self-care (n = 2,337, 34%), home with home health care (n = 1,993, 29%), skilled nursing facility (SNF) (n = 2,170, 32%), hospice (n = 234, 3%), and other health care facilities (n = 75, 1%). Those discharged to hospice and other health care facilities were not included in the remainder of the analysis. The decision was made to focus the remainder of the analysis on the three prominent discharge locations: home with self-care, home with home health care, and SNFs (n = 6,500).

30-day rehospitalization patterns for all patients 75 and older discharged from June 2007 to May 2008.

Figure. 30-day rehospitalization patterns for all patients 75 and older discharged from June 2007 to May 2008.

The highest rehospitalization rates by discharge location were for those discharged to SNFs (15%), followed by discharge home with home health care (13%) and then discharged home with self-care (8%), suggesting that those discharged to SNFs or home with home health care were more vulnerable to rehospitalization within 30 days. When compared with those who were not rehospitalized, index admission characteristics of those patients who were rehospitalized differed by age and length of stay (p < 0.05) but not by sex. Patients with an index length of stay of more than 5 days had a higher rate of rehospitalization than those whose length of stay was less than 5 days (Table 1).

Index Admission Characteristics of Rehospitalized and Non-Rehospitalized Patients

Table 1: Index Admission Characteristics of Rehospitalized and Non-Rehospitalized Patients

Cardiovascular disease was the most common index principal diagnosis for individuals rehospitalized and those not rehospitalized as compared with other index diagnoses. Within the category of all cardiovascular disease, congestive heart failure (CHF) (p < 0.001), ischemic heart disease (IHD) (p = 0.02), and cerebrovascular disease (p = 0.01) were the most frequent index admission diagnoses in those who were rehospitalized. As a whole, many other cardiac conditions such as syncope, atrial fibrillation, arrhythmias, abdominal aortic aneurysm, and peripheral vascular disease did not fit into the established categories as described above; however, they were too few to be considered as an individual category.

The second most frequent index admission diagnoses of those who were rehospitalized were infectious diseases (p < 0.01), with significantly more people with urinary tract infections and pneumonia than those who were not rehospitalized (p = 0.01). Other infectious diseases included viral meningitis, cellulitis, sepsis, osteomyelitis, acute pharyngitis, abscess of appendix, empyema, fever, herpes zoster, and peritoneal abscess. Finally, those who had an index admission diagnosis related to musculoskeletal disorders were less likely to be rehospitalized than those with other diagnoses in this category (p < 0.01). Within this category, people were more often admitted with a diagnosis of hip fracture (Table 1). Other musculoskeletal diagnoses included spondylolisthesis, rheumatoid arthritis, rotator cuff syndrome, and spinal stenosis. Approximately 0.07% (n = 77) of those rehospitalized had the same diagnosis for the second admission as they had for their index admission (Table 2).

Overlapping Index Admission Principal Diagnosis and Rehospitalization Diagnosis (N = 6,500)

Table 2: Overlapping Index Admission Principal Diagnosis and Rehospitalization Diagnosis (N = 6,500)

Of the 6,809 patients discharged, 4% were readmitted within 0 to 7 days and 8% were readmitted within 8 to 30 days, with an overall rehospitalization rate of 12%. Those who were discharged to a SNF or sent home with home health care had a 7-day rehospitalization rate of 5% as compared with those discharged home with self-care (3%). A similar finding was obtained for the 8-to-30-day rehospitalization rates: Those discharged to a SNF had the highest rehospitalization rate (10%) followed by those discharged home with home health care (9%) and then home with self-care (6%) (Table 3).

Comparison of Rehospitalization Within 0 to 7 Days and 8 to 30 Days by Discharge Location

Table 3: Comparison of Rehospitalization Within 0 to 7 Days and 8 to 30 Days by Discharge Location

No major differences were found in index admission principal diagnosis between those rehospitalized within 7 days as compared with those rehospitalized within 8 to 30 days. Cardiovascular conditions remained the most common diagnoses for rehospitalization; IHD and CHF were the primary cardiovascular disorders that led to rehospitalization in both groups. The significant difference was that individuals whose index diagnosis was malignancy were more likely to be admitted within 7 days as compared with those with other index diagnoses (p < 0.05) (Table 4). Those with respiratory conditions other than chronic obstructive pulmonary disease (COPD) were most likely to be rehospitalized within 8 to 30 days (p = 0.02).

Index Admission Characteristics of Patients Discharged to Home and Skilled Nursing Facilities (SNFs)

Table 4: Index Admission Characteristics of Patients Discharged to Home and Skilled Nursing Facilities (SNFs)

Significant differences were identified in rehospitalization diagnosis according to initial discharge location. Individuals discharged to SNFs (highest rehospitalization rate) were more likely to be rehospitalized with infectious diseases (34% versus 25% for home health care and 12% for those discharged home with self-care). The most frequent rehospitalization diagnoses for those discharged home with home health care were cardiovascular disorders. Finally, those patients who were discharged home with self-care were more often rehospitalized with cardiovascular diagnoses (45%) and digestive disorders (14%) than those discharged to other locations (Table 5).

Principal Rehospitalization Diagnosis by Initial Discharge Location

Table 5: Principal Rehospitalization Diagnosis by Initial Discharge Location

Discussion

The findings of this descriptive study of characteristics, discharge location, and initial and rehospitalization diagnoses of adults 75 and older discharged from a community hospital provides data that can be used by nurses in various health care settings to identify those at risk for rehospitalization and develop interventions aimed at reducing rehospitalization. In this study, many people were rehospitalized within 7 days of discharge, which supports the need for early intervention before discharge and within a week of discharge.

The rate of rehospitalizations in this study population was lower than has been reported in other studies (Jencks et al., 2009; Steiner, Barrett, & Hunter, 2010). This is in large part explained by the fact that other data examined discharges (which include patients with multiple readmissions), as opposed to this study, in which only one index hospitalization per patient was studied. This study limited the age of the population to 75 and older, whereas other studies used the typical Medicare cut-off age of 65. The results of this study suggest that some older adults discharged to different post-acute settings may be more vulnerable to complications, resulting in an increased risk for 30-day rehospitalization and that nursing interventions targeted at the most common clinical conditions associated with rehospitalization may have an important impact on rehospitalization rates.

Patients Discharged Home with Self-Care

As evidenced in our study, cardiovascular and digestive disorders are the most common rehospitalization diagnoses among individuals discharged home with self-care, indicating the importance of early identification of those at risk and intervening before discharge. Better coordination of care and appropriate follow up once a person goes home may be one way to reduce the risk of 30-day rehospitalization. An example of such an intervention is the use of APNs to coordinate the care of older adults as they transition from hospital to home. For more than a decade, Naylor et al. (1999, 2004, 2009) have provided evidence that a nurse-led transitional model of care can improve health outcomes of older adults who are at high risk for rehospitalization. In the Transitional Care Model (TCM), an APN assumes a primary role, collaborating with older adults, family members, and other health care professionals to coordinate care during hospitalization and after discharge to home. The TCM has shown significant benefits; however, it is not without limitations. The research was conducted in large urban settings, which may present challenges in rural areas where there are fewer APNs. Existing data show that more APNs are located in urban areas (85%) than in remote rural areas (5.5%) (Lin, Burns, & Nochajski, 1997).

Despite this limitation, evidence from Naylor and colleagues’ research supports the success of this intervention in reducing rehospitalization and improving quality of care for older adults, showing the value of initiating care coordination early, using an interdisciplinary team approach, and the importance of effective communication across health care settings. Naylor and colleagues continue to refine TCM through multiple research initiatives.

Other interventions shown to be helpful in reducing rehospitalizations from home settings have implications for nursing practice. The implementation of the Care Transitions Intervention®, which focuses on improving quality of care and ensuring safety during care transition, has been shown to reduce rehospitalizations in community-dwelling adults 65 and older (Coleman, Smith, et al., 2004; Coleman, Parry, Chalmers, & Min, 2006). The Care Transitions Intervention consists of a transition coach (APNs or nurses) who worked within an integrated health care delivery system. The 4-week intervention focuses on enhancing self-management skills of older adults who are discharged home. The four main components of the intervention include medication self-management, patient-centered health records, primary care and specialist follow up, and knowledge of “red flag” warning symptoms or signs indicative of a worsening condition. Even though this intervention has shown to be an effective way to reduce 30-day rehospitalization, it may not be the best approach for all older adults. The study design included a homogenous sample with predominantly White and highly educated older adults (Coleman et al., 2006). More research is needed to explore outcomes of this type of strategy in an ethnically and racially diverse underserved population. Regardless, the success of this model has led to CMS initiating quality improvement projects using this model of care in various states across the country.

Considering the effectiveness of the Care Transitions Intervention, CMS funded an initiative for Medicare Quality Improvement Organizations (QIOs) to implement strategies aimed at reducing 30-day rehospitalizations in selected communities across the United States. The QIOs had the flexibility to implement community-based interventions, based on the needs of the community (Ventura, Brown, Archibald, Goroski, & Brock, 2010). The preliminary success of these programs has led to further CMS funding opportunities for community-based organizations partnering with acute care hospitals to establish programs improving transitions from one area of care to another (HealthCare.gov, 2011). This provides an opportunity for aging networks, such as Area Agencies on Aging and Aging and Disability Resource Centers, to establish new care transitions partnerships (U.S. Administration on Aging, 2011) that can improve health outcomes for older adults.

As the need for community-based care interventions increases and health care professionals struggle to implement effective strategies, it is essential to consider other successful programs such as the Program of All-Inclusive Care for the Elderly (PACE). PACE is an innovative, comprehensive model of care aimed at keeping community-dwelling older adults in the home who otherwise would need nursing home-level care (Eng, Pedulla, Eleazer, McCann, & Fox, 1997). Success of the program has led to federal support through Medicare reimbursement. PACE enables older adults to remain in their homes through integration of services in an effort to meet complex health, functional, and social needs. PACE participants are certified that they require nursing home care but can live safely in their homes. As participants, they are eligible for several services that address chronic care needs, including delivery of medical and supportive services, social services, adult day care, respite care, prescription medications, and home health care (National PACE Association, 2002). Although these interventions have demonstrated effectiveness at reducing 30-day rehospitalization rates, they are limited to community-dwelling older adults and are not available in all 50 states; less than 50% of U.S. states have a PACE program (CMS, 2011a).

Patients Discharged Home with Home Health Care

In our study, the second-highest rehospitalization rate was for those discharged home with home health care. Such older adults are likely to be sicker than those discharged home with self-care (Vasquez, 2008), increasing the risk of rehospitalization. Nationally, close to 30% of Medicare home health episodes end with a hospitalization; nearly a quarter of hospitalizations occur within 7 days of admission to a home health agency, and more than 50% of these patients are rehospitalized within 30 days (Home Health QIOSC, as cited in Vasquez, 2008). In an attempt to reduce rehospitalization rates, home health nurses have implemented strategies such as frontloading visits (i.e., provide more service when they first arrive home after being hospitalized), having a nurse available 24 hours per day, assisting with medication management, providing patient and family education, and offering case management and disease management programs (Briggs Corporation, 2006). Despite having these in place, barriers to care continue to exist, such as ineffective communication between home health nurses and other health care providers, time limitation for assessments and interventions, and poor documentation, putting the patient at risk for rehospitalization within 30 days of discharge with home health care (Vasquez, 2008). In part, some of these barriers are related to financial constraints, as many of the interventions that may improve health outcomes are not being reimbursed. Some other reasons for rehospitalization for this population include development of a new problem and worsening of index admission diagnosis (Madigan, Schott, & Matthews, 2001), further supporting the need for nursing interventions during this vulnerable period.

In our study, individuals discharged home with home health services were more likely to be rehospitalized with cardiovascular diagnoses. Nursing interventions that are focused on identifying those patients at risk for cardiovascular disorders and implementing strategies to address these risks may be an effective way to reduce rehospitalization in this vulnerable population.

Patients Discharged to Skilled Nursing Facilities

The highest rehospitalization rates were found in those discharged from the hospital to SNFs, which is consistent with Medicare data that reports approximately one quarter of Medicare beneficiaries who were discharged from hospitals to SNFs are readmitted within 30 days (Jencks et al., 2009). During the past several decades, SNFs have experienced a dramatic transformation as they attempt to meet the needs of older adults with multiple, complex health problems. Frequently, nurses in SNFs today are providing care for people discharged from acute care who have many risk factors for 30-day rehospitalization. Rehospitalization puts skilled nursing facility residents at risk for iatrogenic problems such as functional decline, falls, delirium, polypharmacy, pressure ulcers, hospital-acquired infections, and others. According to MedPAC (2008) data, nursing home residents with diagnoses such as CHF, respiratory infections, urinary tract infections, and sepsis and electrolyte imbalances accounted for more than 70% of potentially avoidable 30-day rehospitalizations (Donelan-McCall, Eilertsen, Fish, & Kramer, 2006); individuals in the current study were most likely to be rehospitalized with principal diagnoses related to infectious disease. We have also analyzed our data by discharge to SNFs (rather than by individual patients as in this study) and found that respiratory conditions, renal failure (presumably related to volume depletion), and urinary tract infection were other common conditions associated with readmission (Ouslander, Diaz, Hain, & Tappen, 2011).

Interventions are available that focus on detecting high-risk residents and improving communication with primary care providers. Interventions to Reduce Acute Care Transfers (INTERACT II) is a quality improvement intervention that uses a set of comprehensive clinical tools and strategies designed to alert nurses to early changes in residents and facilitate communication of these changes to the primary care provider so the nurse can intervene before rehospitalization is necessary (Ouslander et al., 2009). All of these tools are available online at http://interact2.net.

Another innovative program aimed at improving care of residents in SNFs is the Evercare model. The Evercare model has enhanced the care of nursing home residents by using APNs to care for individuals who are enrolled in a risk-based health maintenance organization, with nursing home costs covered by Medicaid or private insurance. The APNs and care managers work with primary care providers, facilities, and families to provide intensive primary care and prevention services to those in long-term care. Kane, Keckhafer, Flood, Bershadsky, and Siadaty (2003) explored the hospitalization rates of Evercare enrollees in comparison to a control group that consisted of nursing home residents at the same site and not enrolled in Evercare and residents of other nursing homes who did not participate in the Evercare program. The researchers concluded that Evercare residents were less likely to be hospitalized than the control group residents, who were twice as likely to be hospitalized.

Despite having effective evidence-based strategies aimed at reducing rehospitalizations in this population, many factors will need to be considered before a noticeable improvement is seen. First, current reimbursement for care does not support care coordination, often resulting in fragmentation of care (Mor, Intrator, Feng, & Grabowski, 2010). In SNFs, some transfers may be unavoidable due to higher acuity of those receiving skilled nursing care, but many can be prevented by earlier identification and management of the resident, improved communication between health care professionals, and involving the resident and family in the decision-making process (Lamb, Tappen, Diaz, Herndon, & Ouslander, 2011).

Regardless of where an older adult is receiving care, it is important to consider all factors that put the person at risk for rehospitalization. MedPAC estimates that approximately 76% of rehospitalizations can be avoided (Boutwell, Jencks, Nielsen, & Rutherford, 2009). Many factors contribute to 30-day rehospitalization, some of which are related to patient-level factors and others due to system-level factors. Some of the patient-level factors include multiple comorbidities, decline in physical and cognitive function, and health behaviors that are incongruent with the prescribed regimen. Some of the system-level factors include ineffective communication between health care professionals as a person transitions from one health care setting to another and lack of care coordination (Naylor et al., 2009), supporting the need to address gaps in care as older adults transition.

Other Models of Care

The patient-centered medical home, where a single provider is responsible for coordinating the care of an individual, is one model of care. The use of chronic care coordinators in patient-centered medical homes has been shown to reduce health care costs while improving clinical outcomes. The Johns Hopkins Guided Care program ( http://www.guidedcare.org) has demonstrated annual Medicare net cost savings of $75,000 per nurse care coordinator by reducing hospitalization days, having fewer emergency department visits, and fewer days in a SNF (Leff et al., 2009).

Accountable care organizations (ACOs), where the care coordination is along the continuum of care, is another model of care that may prove beneficial in reducing potentially avoidable 30-day rehospitalization. ACOs have a broader scope of care coordination across the entire health care continuum. In March 2011, CMS (2011b) published in the Federal Register the proposed rule to implement ACOs.

Both of the aforementioned models have generated significant controversy among health care professionals. Demonstration programs that will be supported by the new CMS Innovation Center, authorized in the Patient Protection and Affordable Care Act of 2010, may provide nurses with a wide variety of opportunities to participate in such research and demonstration efforts. Nurses should be aware of health care initiatives that may affect their practice and be prepared to assume a leadership role. However, not all nurses will have this opportunity, so it is important that nurses assess for risk factors for 30-day rehospitalization and implement strategies aimed at reducing risk.

Limitations

This study has several limitations. First, data were collected from one non-teaching hospital with a mostly White upper socioeconomic patient population; second, no direct data were collected by examining patients. In addition, the analysis did not control for other variables and important unknown confounders of potential importance such as age, comorbidity, and clinical conditions not captured by claims data (Strom, 2001). Despite these limitations, the findings from this study support the need for further exploration of the effectiveness of interventions aimed at improving care of older adults during a time at which they may be vulnerable for poor health outcomes, such as 30-day rehospitalization.

Conclusion and Implications

Some of the interventions that focus on improving care of older adults as they transition from one health care setting to another are consistent, regardless of the discharge site; however, interventions may be specific to the setting (Table 6). Interventions that are similar across settings include: (a) completing a comprehensive geriatric assessment aimed at identifying those at risk for 30-day rehospitalization and establishing patient- and family-centered approaches to care; (b) care coordination in collaboration with the interprofessional team; and (c) and timely and appropriate follow-up medical care.

Suggestions for Interventions and Transition Models of Care Specific to Health Care Setting

Table 6: Suggestions for Interventions and Transition Models of Care Specific to Health Care Setting

The findings from this project may be used to guide nursing interventions that are focused on reducing potentially avoidable 30-day rehospitalizations. Nursing has a strong presence in SNFs and home health care, providing indirect and direct care to patients. Therefore, nurses will play an important role as members of an interprofessional team caring for older adults during the transition period from hospital to SNF or home with home health care or home with self-care.

As health care reform evolves and health care professionals struggle to provide cost-effective, quality care in a fragmented health care system, it is critical to improve transition of care across health care settings. More research that explores the financial benefit of strategies aimed at reducing 30-day rehospitalizations is needed. Under a bundled payment system, it will be essential for health care facilities to dedicate resources aimed at reducing 30-day rehospitalizations.

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Index Admission Characteristics of Rehospitalized and Non-Rehospitalized Patients

Characteristic Total (N = 6,500) Rehospitalized (n = 779) Not Rehospitalized (n = 5,721) Fvalue pValue
Mean age, years (SD) 83 (5.7) 84 (5.5) 83 (5.7) 11.41 <0.0007**
Mean length of stay for index admission, days (SD) 5 (4.8) 7 (6.1) 5 (4.5) 107 <0.0007**
Totaln(%) Rehospitalizedn(%) Not Rehospitalizedn(%) χ2 pValue
Sex 0.0028 0.95
  Women 3,577 (55) 428 (55) 3,149 (55)
  Men 2,923 (45) 351 (45) 2,572 (45)
Index admission discharge location 49.70 <0.0001**
  Home with self-care 2,337 (36) 193 (25) 2,144 (37)
  Skilled nursing facility 2,170 (33) 319 (41) 1,851 (32)
  Home with home health care 1,993 (31) 267 (34) 1,726 (30)
Index admission principal diagnosis
  All cardiovascular disorders 2,119 (33) 266 (34) 1,853 (32) 0.96 0.32
    Congestive heart failure 422 (6) 79 (10) 343 (6) 19.41 <0.0001**
    Ischemic heart disease 395 (6) 61 (8) 334 (6) 4.76 0.02*
    Cerebrovascular accident 260 (4) 19 (2) 241 (4) 5.61 0.01**
    Other cardiovascular disorder 1,042 (16) 107 (14) 935 (16) 3.46 0.06
  All infectious disease 1,131 (17) 165 (21) 966 (17) 8.80 0.003**
    Pneumonia 373 (6) 60 (8) 313 (5) 6.30 0.01**
    Urinary tract infection 116 (2) 22 (3) 94 (2) 5.45 0.01**
    Other infectious disease 642 (10) 83 (11) 559 (10) 0.60 0.43
  All musculoskeletal disorders 898 (14) 78 (10) 820 (14) 10.74 0.001**
    Hip fracture 247 (4) 29 (4) 218 (4) 0.01 0.90
    Other musculoskeletal disorder 651 (10) 49 (6) 602 (11) 13.62 0.0002**
  All digestive disorders 693 (11) 74 (9) 619 (11) 1.25 0.26
  All malignant disorders 409 (6) 40 (5) 369 (6) 2.01 0.15
  All respiratory disorders 352 (5) 50 (6) 302 (5) 1.73 0.18
    Chronic obstructive pulmonary disease 183 (3) 26 (3) 157 (3) 0.88 0.34
    Other respiratory disorder 169 (3) 24 (3) 145 (3) 0.80 0.36
  Renal conditionsa 224 (3) 32 (4) 192 (3) 1.16 0.28
  Other diagnoses 674 (10) 74 (9) 600 (10) 0.72 0.39

Overlapping Index Admission Principal Diagnosis and Rehospitalization Diagnosis (N = 6,500)

Principal Diagnosis Index Admission Principal Diagnosis,n(%) Rehospitalized with Same Diagnosis,n(%)
All cardiovascular disorders 2,119 (33) 156 (7)
  Congestive heart failure 422 (6) 35 (8)
  Ischemic heart disease 395 (6) 12 (3)
  Cerebrovascular accident 260 (4) 9 (3)
  Other cardiovascular disorder 1,042 (16) 31 (3)
All infectious disease 1,131 (17) 77 (7)
  Pneumonia 373 (6) 16 (4)
  Urinary tract infection 116 (2) 3 (3)
  Other infectious disease 642 (10) 33 (5)
All musculoskeletal disorders 898 (14) 16 (2)
  Hip fracture 247 (4) 2 (0.8)
  Other musculoskeletal disorder 651 (10) 11 (2)
All digestive disorders 693 (11) 25 (4)
All malignant disorders 409 (6) 17 (4)
All respiratory disorders 352 (5) 9 (3)
  Chronic obstructive pulmonary disease 183 (3) 4 (2)
  Other respiratory disorder 169 (3) 3 (2)
Renal disordersa 224 (3) 8 (4)
Other diagnoses 674 (10) 16 (2)

Comparison of Rehospitalization Within 0 to 7 Days and 8 to 30 Days by Discharge Location

Discharge Location Total Number of Discharged Patientsn(%) 0-to-7-Day Rehospitalizationn(%) 8-to-30-Day Rehospitalizationn(%) 30-Day Rehospitalizationn(%)
Home with self-care 2,337 (34) 61 (3) 132 (6) 193 (8)
Home with home health care 1,993 (29) 95 (5) 172 (9) 267 (13)
Skilled nursing facility 2,170 (32) 110 (5) 209 (10) 319 (15)
Hospice 234 (3) 1 (0.4) 7 (3) 8 (3)
Other facility 75 (1) 1 (1.3) 4 (5) 5 (7)
Total 6,809 (100) 268 (4) 524 (8) 792 (12)

Index Admission Characteristics of Patients Discharged to Home and Skilled Nursing Facilities (SNFs)

Characteristic Patients with at Least One Rehospitalization Within 7 Days of Discharge (n= 266) Patients with at Least One Rehospitalization Within 8 to 30 Days of Discharge (n= 513) Fvalue pValue
Mean age, years (SD) 84 (5.5) 85 (5.5) 10.19 <0.0001**
Mean length of stay for index admission, days (SD) 8 (6.7) 7 (5.8) 56.26 <0.0001**
n(%) n(%) χ2 pValue
Sex 0.03 0.86
  Women 145 (55) 283 (55)
  Men 121 (45) 230 (45)
Index admission discharge location 0.81 0.66
  SNF 110 (41) 209 (41)
  Home with home health care 95 (36) 172 (34)
  Home with self-care 61 (23) 132 (26)
Index admission principal diagnosis
All cardiovascular disorders 93 (35) 173 (34) 0.35 0.55
  Ischemic heart disease 26 (10) 35 (7) 2.11 0.14
  Congestive heart failure 23 (9) 56 (11) 0.99 0.31
  Cerebrovascular accident 5 (2) 14 (3) 0.53 0.46
  Other cardiovascular disorder 39 (15) 68 (13) 0.29 0.58
All infectious disease 54 (20) 111 (22) 0.18 0.66
  Pneumonia 20 (8) 40 (8) 0.01 0.89
  Urinary tract infection 5 (2) 17 (3) 1.31 0.25
  Other infectious disease 29 (11) 54 (11) 0.02 0.87
All musculoskeletal disorders 28 (11) 50 (10) 0.11 0.73
  Hip fracture 8 (3) 21 (4) 0.57 0.44
  Other musculoskeletal disorder 20 (8) 29 (6) 1.03 0.30
All digestive disorders 32 (12) 42 (8) 3.00 0.08
All malignant disorders 20 (8) 20 (4) 4.71 0.02
All respiratory disorders 12 (5) 38 (7) 2.44 0.11
  Chronic obstructive pulmonary disease 9 (3) 17 (3) 0.0026 0.95
  Other respiratory disorder 3 (1) 21 (4) 5.16 0.02*
Renal disordersa 8 (3) 24 (5) 1.24 0.26
Other diagnoses 19 (7) 55 (11) 2.60 0.10

Principal Rehospitalization Diagnosis by Initial Discharge Location

Rehospitalization Principal Diagnosis Home with Self-Care (n= 193)n(%) Home with Home Health Care (n= 267)n(%) Skilled Nursing Faculty (n= 319)n(%)
All cardiovascular disorders 87 (45) 89 (33) 88 (28)
  Congestive heart failure 26 (13) 37 (14) 39 (12)
  Ischemic heart disease 13 (7) 9 (3) 8 (3)
  Cerebrovascular accident 8 (4) 7 (3) 13 (4)
  Other cardiovascular disorder 40 (21) 36 (13) 28 (9)
All infectious disease 23 (12) 66 (25) 108 (34)
  Pneumonia 7 (4) 23 (9) 36 (11)
  Urinary tract infection 2 (1) 3 (1) 7(2)
  Other infectious disease 14 (7) 40 (15) 65 (20)
All musculoskeletal disorders 3 (2) 17 (6) 24 (8)
  Hip fracture 1 (1) 4 (1) 9 (3)
  Other musculoskeletal disorder 2 (1) 19 (7) 15 (5)
All digestive disorders 27 (14) 23 (9) 26 (8)
All malignant disorders 15 (8) 14 (5) 5 (2)
All respiratory disorders 13 (7) 13 (5) 16 (5)
  Chronic obstructive pulmonary disease 6 (3) 1 (0.4) 7 (2)
  Other respiratory disorder 7 (4) 12 (4) 9 (3)
All renal disordersa 2 (1) 18 (7) 19 (6)
Other diagnoses 23 (12) 27 (10) 33 (10)

Suggestions for Interventions and Transition Models of Care Specific to Health Care Setting

Discharge Site Major Diagnoses Suggested Interventions and Transition Models of Care
Home with self-care

Cardiovascular disorders

Digestive disorders

Educating patient/family regarding when to contact health care provider

Telephone follow-up call within 48 hours of discharge

Transitional Care Model (Naylor et al., 1999, 2004; Naylor, Feldman, et al., 2009)

Care Transitions Intervention® (Coleman, Smith, et al., 2004; Coleman, Parry, Chalmers, & Min, 2006)

Program of All-Inclusive Care for the Elderly (PACE) (National PACE Association, 2002)

Home with home health care

Cardiovascular disorders

All infectious disease

Transitional Care Model

Educate and train nurses how to conduct and interpret a comprehensive geriatric assessment

Medication reconciliation; collaborate with pharmacy

Consultation with gerontological nurse practitioner or consider employing one

Skilled nursing facility

Infectious disease

All musculoskeletal disorders

Interventions to Reduce Acute Care Transfers (INTERACT II) (Ouslander et al., 2009)

Evercare model

Identify high-risk medications that may increase risk adverse events; consult with pharmacy

Fall prevention program

Implement evidence-based protocol for prevention of infections (e.g., pneumonia, urinary tract infections)

Keypoints

Hain, D.J., Tappen, R., Diaz, S. & Ouslander, J.G. (2012). Characteristics of Older Adults Rehospitalized Within 7 and 30 Days of Discharge: Implications for Nursing Practice. Journal of Gerontological Nursing, 38(8), 32–44.

  1. Rehospitalization within 30 days of discharge from a hospital is a serious problem that can lead to poor health outcomes for older adults, along with increased health care costs.

  2. Results from this retrospective study revealed that 30-day rehospitalization for older adults 75 and older were highest if discharged to a skilled nursing facility, followed by discharge home with home health care and finally home with self-care.

  3. Older adults are vulnerable to complications that may lead to potentially avoidable 30-day rehospitalization during transition from hospital to other health care settings.

  4. Nurses provide care across health care settings; therefore, they have an important role as members of interprofessional teams in improving care for older adults during transitions.

Authors

Dr. Hain is Assistant Professor and Lead ANP/GNP Faculty, Dr. Tappen is Eminent Scholar and Professor, Christine E. Lynn College of Nursing, Dr. Diaz is Healthy Aging Research Initiative Senior Project Coordinator, and Dr. Ouslander is Professor and Senior Associate Dean, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This project was supported by the Retirement Research Foundation.

Address correspondence to Debra J. Hain, PhD, APRN, GNP-BC, Assistant Professor and Lead ANP/GNP Faculty, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431; e-mail: dhain@fau.edu.

Received: January 12, 2012
Accepted: March 02, 2012
Posted Online: July 15, 2012

10.3928/00989134-20120703-05

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