title: The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions.
abstract: This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Naylor
authors.forename: K M
authors.initials: KM
authors.lastname: McCauley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000451:nursing* / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D015143:Philadelphia; D018709:Statistics, Nonparametric; D013997:Time Factors