A Hybrid Transitional Care Program

BACKGROUND: Older adults have complex medical conditions and multiple comorbidities that make them extremely vulnerable when discharged from hospital to home or community settings. Discharge failures and communication gaps lead to negative outcomes, both short term and long term (Naylor, Annu Rev Nurs Res. 2003;20:127-147). METHODS: A 9-month study including 89 heart failure (HF) patients was undertaken. These patients were considered at high risk for rehospitalization using definitive inclusion criterion. This criterion was clinically driven and assessed at point of entry into the hospital. Health literacy screening was done before educational sessions, using "The Newest Vital Sign Assessment Tool." This tool has been validated against previous measures of health literacy such as the TOFHLA (Osborn et al, Am J Health Behav. 2007;31:36-46). Reconciliation of medications upon hospital admission, discharge, and during the 6-month follow-up period ensured that all providers were aware of the patient's medications upon discharge. A follow-up appointment with the patient's cardiologist was also arranged within 7 to 10 days postdischarge. The comparison group was all other HF patients within the same hospital setting. Exclusion criteria also included nursing home residents and anyone who declined enrollment into the study. RESULTS: Continual identification of system or process and communication gaps postdischarge helped improve the continuum of care. Key findings from this study include a 30-day readmission rate for the study group of 15%, with an expected rate of 20%. Observed mortality rate was 2% for the study group with an expected rate of 7%. CONCLUSIONS: A successful transitional HF program can reduce readmissions, length of stay, cost of hospitalization, and mortality rates. Adaptation of this model elsewhere should be a consideration.