Support From Hospital to Home for Elders: A Randomized Trial
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
Abstract
Background:
Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success.
Objective:
To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital.
Design:
Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532)
Setting:
Publicly funded urban hospital in Northern California.
Patients:
Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese).
Intervention:
Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner.
Measurements:
Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals.
Results:
There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days).
Limitations:
This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered.
Conclusion:
A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population.
Primary Funding Source:
Gordon and Betty Moore Foundation.
Get full access to this article
View all available purchase options and get full access to this article.
Supplemental Material
Supplement 1. Methods for RN Training, Ascertainment of Outcomes, and Sensitivity Analyses
References
1.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354]
2.
Oddone EZ, Weinberger M, Horner M, Mengel C, Goldstein F, Ginier P, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. J Gen Intern Med. 1996;11:597-607. [PMID: 8945691]
3.
Centers for Medicare & Medicaid Services. Accountable Care Organizations (ACO). Accessed at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/aco on 8 August 2013.
4.
U.S. Department of Health and Human Services. Understanding the Affordable Care Act: About the Law. Accessed at www.hhs.gov/healthcare/rights/index.html on 4 August 2014.
5.
Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23:1228-33. [PMID: 18452048] doi: 10.1007/s11606-008-0618-9
6.
Brown-Williams H, Neuhauser L, Ivey S, Graham C, Poor S, Tseng W, et al. From Hospital to Home: Improving Transitional Care for Older Adults. Berkeley, CA: University of California, Berkeley; 2006. Accessed at www.healthresearchforaction.org/sites/default/files/REPORT_PUBS_H2H%20FNL.pdf on 4 August 2014.
7.
Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Dis Mon. 2002;48:239-48. [PMID: 12021756]
8.
Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PMID: 19189907]
9.
Naylor MD. Transitional care of older adults. Annu Rev Nurs Res. 2002;20:127-47. [PMID: 12092508]
10.
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-84. [PMID: 15086645]
11.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-8. [PMID: 17000937]
12.
Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9:1-4. [PMID: 15181894]
13.
Project BOOST Team. Overview: Project BOOST Implementation Toolkit. Accessed at www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx on 4 August 2014.
14.
Hansen LO, Greenwald JL, Budnitz T, Howell E, Halasyamani L, Maynard G, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8:421-7. [PMID: 23873709] doi: 10.1002/jhm.2054
15.
Shin H, Bruno R. Language Use and English-Speaking Ability: 2000. Census 2000 Brief. Washington, DC: U.S. Census Bureau; 2003. Accessed at www.census.gov/prod/2003pubs/c2kbr-29.pdf on 28 July 2014.
16.
Marengoni A, Winblad B, Karp A, Fratiglioni L. Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden. Am J Public Health. 2008;98:1198-200. [PMID: 18511722] doi: 10.2105/AJPH.2007.121137
17.
Society of Hospital Medicine. How to Use Project BOOST Implementation Toolkit. Accessed at https://store.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/Boost/Home/How_To_Use.aspxon 6 August 2014.
18.
Joint Commission Resources. Project RED. Accessed at www.jcrinc.com/about-jcr/project-red on 21 April 2014.
19.
Lewin ME, Altman S, eds. America's Health Care Safety Net: Intact but Endangered. Washington, DC: National Academies Pr; 2000.
20.
Campbell SE, Seymour DG, Primrose WR; ACMEPLUS Project. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age Ageing. 2004;33:110-5. [PMID: 14960424]
21.
Volz A, Schmid JP, Zwahlen M, Kohls S, Saner H, Barth J. Predictors of readmission and health related quality of life in patients with chronic heart failure: a comparison of different psychosocial aspects. J Behav Med. 2011;34:13-22. [PMID: 20658185] doi: 10.1007/s10865-010-9282-8
22.
Cawthon PM, Fox KM, Gandra SR, Delmonico MJ, Chiou CF, Anthony MS, et al; Health, Aging and Body Composition Study. Do muscle mass, muscle density, strength, and physical function similarly influence risk of hospitalization in older adults? J Am Geriatr Soc. 2009;57:1411-9. [PMID: 19682143] doi: 10.1111/j.1532-5415.2009.02366.x
23.
Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002;34:383-9. [PMID: 12038721]
24.
Cunningham PJ, Bazzoli GJ, Katz A. Caught in the competitive crossfire: safety-net providers balance margin and mission in a profit-driven health care market. Health Aff (Millwood). 2008;27:w374-82. [PMID: 18697764] doi: 10.1377/hlthaff.27.5.w374
25.
Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368:1175-7. [PMID: 23465069] doi: 10.1056/NEJMp1300122
26.
Jha AK. BOOST and readmissions: thinking beyond the walls of the hospital [Editorial]. J Hosp Med. 2013;8:470-1. [PMID: 23873761] doi: 10.1002/jhm.2069
27.
Ness D, Kramer W. Reducing Hospital Readmissions: It's About Improving Patient Care. 16 August 2013. Accessed at http://healthaffairs.org/blog/2013/08/16/reducing-hospital-readmissions-its-about-improving-patient-care on 22 April 2014.
28.
Sudore RL, Landefeld CS, Williams BA, Barnes DE, Lindquist K, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med. 2006;21:867-73. [PMID: 16881949]
29.
Searight HR. Efficient counseling techniques for the primary care physician. Prim Care. 2007;34:551-70, vi-vii. [PMID: 17868759]
30.
Huang L. Krames On-Demand (KOD). J Med Libr Assoc. 2006;94:234-5.
31.
Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90. [PMID: 12523921]
32.
Schillinger D, Handley M, Wang F, Hammer H. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care. 2009;32:559-66. [PMID: 19131469] doi: 10.2337/dc08-0787
33.
Operario D, Adler NE, Williams DR. Subjective social status: reliability and predictive utility for global health. Psychol Health. 2004;19:237-46.
34.
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220-33. [PMID: 8628042]
35.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914-9. [PMID: 14044222]
36.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179-86. [PMID: 5349366]
37.
de Jager CA, Budge MM, Clarke R. Utility of TICS-M for the assessment of cognitive function in older adults. Int J Geriatr Psychiatry. 2003;18:318-24. [PMID: 12673608]
38.
Debling D, Amelang M, Hasselbach P, Stürmer T. Assessment of cognitive status in the elderly using telephone interviews. Z Gerontol Geriatr. 2005;38:360-7. [PMID: 16244822]
39.
Centers for Disease Control and Prevention. 2008 National Health Interview Survey (NHIS): Public Use Data Release. 2009. Accessed at http://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2008/srvydesc.pdf on 6 August 2014.
40.
WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97:1183-94. [PMID: 12199834]
41.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737-44. [PMID: 10568646]
42.
Reuland DS, Cherrington A, Watkins GS, Bradford DW, Blanco RA, Gaynes BN. Diagnostic accuracy of Spanish language depression-screening instruments. Ann Fam Med. 2009;7:455-62. [PMID: 19752474] doi: 10.1370/afm.981
43.
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-94. [PMID: 15343421]
44.
Sarkar U, Schillinger D, López A, Sudore R. Validation of self-reported health literacy questions among diverse English and Spanish-speaking populations. J Gen Intern Med. 2011;26:265-71. [PMID: 21057882] doi: 10.1007/s11606-010-1552-1
45.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373-83. [PMID: 3558716]
46.
Kleinbaum DG, Klein M. Survival Analysis: A Self-Learning Text. 3rd ed. New York: Springer; 2012.
47.
Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7:147-77. [PMID: 12090408]
48.
Hernán MA, Hernández-Díaz S, Robins JM. Randomized trials analyzed as observational studies. Ann Intern Med. 2013;159:560-2. [PMID: 24018844]
49.
Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, et al. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2010:CD000313. [PMID: 20091507] doi: 10.1002/14651858.CD000313.pub3
50.
Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-28. [PMID: 22986379] doi: 10.7326/0003-4819-157-6-201209180-00006
51.
Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155:520-8. [PMID: 22007045] doi: 10.7326/0003-4819-155-8-201110180-00008
52.
McCarthy D, Johnson MB, Audet AM. Recasting readmissions by placing the hospital role in community context. JAMA. 2013;309:351-2. [PMID: 23340635] doi: 10.1001/jama.2013.1
53.
Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20. [PMID: 10029122]
54.
Gerhardt G, Yemane A, Hickman P, Oelschlaeger A, Rollins E, Brennan N. Data Shows Reduction in Medicare Hospital Readmission Rates During 2012. Medicare & Medicaid Research Review. 2013;3. Accessed at www.cms.gov/mmrr/Downloads/MMRR2013_003_02_b01.pdf on 4 August 2014.
55.
Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156:673-83. [PMID: 22586006] doi: 10.7326/0003-4819-156-10-201205150-00003
56.
Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370:1029-38. [PMID: 24620866] doi: 10.1056/NEJMsa1308261
Information & Authors
Information
Published In
Annals of Internal Medicine
Volume 161 • Number 7 • 7 October 2014
Pages: 472 - 481
History
Published online: 7 October 2014
Published in issue: 7 October 2014
Keywords
Copyright
© 2014 American College of Physicians.
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
Download article citation data for:
Support From Hospital to Home for Elders: A Randomized Trial. Ann Intern Med.2014;161:472-481. [Epub 7 October 2014]. doi:10.7326/M14-0094
Support From Hospital to Home for Elders: A Randomized Trial. Ann Intern Med.2014;161:472-481. [Epub 7 October 2014]. doi:10.7326/M14-0094
View More
Login Options:
Purchase
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.
Create your Free Account
You will be redirected to acponline.org to create an account that will provide access to Annals.
Comments
0 Comments