The rural Transitions Nurse Program was associated with increased primary care visits within 14 days of discharge (OR 2.24; 95% CI 2.05-2.45) and reduced 30-day mortality (HR 0.33; 95% CI 0.21-0.53).
Cohort (n=9,003)
Yes
Does a rural Transitions Nurse Program improve early primary care follow-up and reduce readmissions in Veterans discharged from urban hospitals?
A rural transitions nurse program significantly increased early primary care follow-up and reduced 30-day mortality among Veterans discharged from urban hospitals to rural homes.
Effect estimate: OR 2.24 (95% CI 2.05-2.45)
BACKGROUND: Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE: To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS: National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES: The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS: The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval CI = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS: TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
Gilmartin et al. (Tue,) conducted a cohort in Veterans transferred from rural areas to urban VA Medical Centers (n=9,003). Rural Transitions Nurse Program (TNP) vs. Usual care was evaluated on PCP visits within 14 days of discharge and all-cause 30-day readmissions (OR 2.24, 95% CI 2.05-2.45). The rural Transitions Nurse Program was associated with increased primary care visits within 14 days of discharge (OR 2.24; 95% CI 2.05-2.45) and reduced 30-day mortality (HR 0.33; 95% CI 0.21-0.53).