A telephone-based Enhanced Discharge Planning Program increased completed physician visits at 30 days versus usual care, but had no effect on patient or caregiver stress or hospital readmissions.
RCT
electronic medical record
Does a telephone-based Enhanced Discharge Planning Program improve stress, health care utilization, readmissions, and mortality in hospitalized older adults at risk of post-discharge complications?
A telephone-based transitional care intervention for at-risk older adults improved 30-day physician follow-up rates but did not significantly reduce hospital readmissions or stress.
PURPOSE OF THE STUDY: To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality. DESIGN AND METHODS: Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs. All patients received a follow-up call at 30 days post discharge to assess psychosocial needs, patient and caregiver stress, and physician follow-up. RESULTS: 83.3% of intervention group participants experienced significant barriers to care. For 73.3% of this group, problems did not emerge until after discharge. Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post discharge. There were no differences between groups on patient or caregiver stress or hospital readmission. IMPLICATIONS: At-risk older adults may benefit from transitional care programs to ensure delivery of care as ordered and address unmet needs. Although patients who received the intervention were more likely to communicate and follow up with their physicians, the absence of impact on readmission suggests that more intensive efforts may be indicated to affect this outcome.
Altfeld et al. (Fri,) conducted a rct in Risk of post-discharge complications. Enhanced Discharge Planning Program vs. Usual care was evaluated on Stress, health care utilization, readmissions, and mortality. A telephone-based Enhanced Discharge Planning Program increased completed physician visits at 30 days versus usual care, but had no effect on patient or caregiver stress or hospital readmissions.