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Naylor MD, Brooten D, Campbell R, et al. Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders: A Randomized Clinical Trial. JAMA. 1999;281(7):613–620. doi:10.1001/jama.281.7.613
Author Affiliations: School of Nursing (Dr Naylor and Mss Campbell and Jacobsen), The Wharton School (Dr Pauly), and School of Medicine (Dr Schwartz), University of Pennsylvania, Philadelphia; School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Brooten); and Division of Nursing, New York University, New York, NY (Dr Mezey).
Context Comprehensive discharge planning by advanced practice
nurses has demonstrated short-term reductions in readmissions of
elderly patients, but the benefits of more intensive follow-up of
hospitalized elders at risk for poor outcomes after discharge has not
Objective To examine the effectiveness of an advanced
practice nurse–centered discharge planning and home follow-up
intervention for elders at risk for hospital readmissions.
Design Randomized clinical trial with follow-up at 2, 6, 12, and
24 weeks after index hospital discharge.
Setting Two urban, academically affiliated hospitals in
Participants Eligible patients were 65 years or older,
hospitalized between August 1992 and March 1996, and had 1 of several
medical and surgical reasons for admission.
Intervention Intervention group patients received a comprehensive
discharge planning and home follow-up protocol designed specifically
for elders at risk for poor outcomes after discharge and implemented by
advanced practice nurses.
Main Outcome Measures Readmissions, time to first readmission,
acute care visits after discharge, costs, functional status,
depression, and patient satisfaction.
Results A total of 363 patients (186 in the control group and 177
in the intervention group) were enrolled in the study; 70% of
intervention and 74% of control subjects completed the trial. Mean age
of sample was 75 years; 50% were men and 45% were black. By week 24
after the index hospital discharge, control group patients were more
likely than intervention group patients to be readmitted at least once
(37.1% vs 20.3%; P<.001). Fewer intervention group
patients had multiple readmissions (6.2% vs 14.5%;P = .01) and the intervention group had fewer hospital days per
patient (1.53 vs 4.09 days; P<.001). Time to first
readmission was increased in the intervention group
(P<.001). At 24 weeks after discharge, total Medicare
reimbursements for health services were about $1.2 million in the
control group vs about $0.6 million in the intervention group
(P<.001). There were no significant group differences in
postdischarge acute care visits, functional status, depression, or
Conclusions An advanced practice nurse–centered discharge
planning and home care intervention for at-risk hospitalized elders
reduced readmissions, lengthened the time between discharge and
readmission, and decreased the costs of providing health care. Thus,
the intervention demonstrated great potential in promoting positive
outcomes for hospitalized elders at high risk for rehospitalization
while reducing costs.
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