title: Hospital discharge planning and continuity of care for aged people in an Italian local health unit: does the care-home model reduce hospital readmission and mortality rates?
abstract: BACKGROUND
  Hospital discharge planning is aimed to decrease length of stay in hospitals as well as to ensure continuity of health care after being discharged. Hospitalized patients in Turin, Italy, who are in need of medical, social and rehabilitative care are proposed as candidates to either discharge planning relying on a care-home model (DPCH) for a period of about 30 days, or routine discharge care. The aim of this study was to evaluate whether a hospital DPCH that was compared with routine care, improved patients' outcomes in terms of reduced hospital readmission and mortality rates in patients aged 64 years and older.
  
  
  METHODS
  In a retrospective observational cohort study a sample of 380 subjects aged 64 years and over was examined. Participants were discharged from the hospital S. Giovanni Bosco in Turin, Italy from March 1st, 2005 to February 28th, 2006. Of these subjects, 107 received routine discharge care while 273 patients were referred to care-home (among them, 99 received a long-term care intervention (LTCI) afterwards while 174 did not). Data was gathered from various administrative and electronic databases. Cox regression models were used to evaluate factors associated with mortality and hospital readmission.
  
  
  RESULTS
  When socio-demographic factors, underlying disease and disability were taken into account, DPCH decreased mortality rates only if it was followed by a LTCI: compared to routine care, the Hazard Ratio (HR) of death was 0.36 (95% Confidence Interval (CI): 0.20 - 0.66) and 1.15 (95%CI: 0.77 - 1.74) for DPCH followed by LTCI and DPCH not followed by LTCI, respectively. On the other hand, readmission rates did not significantly differ among DPCH and routine care, irrespective of the implementation of a LTCI: HRs of hospital readmission were 1.01 (95%CI: 0.48 - 2.24) and 1.18 (95%CI: 0.71 - 1.96), respectively.
  
  
  CONCLUSIONS
  The use of DPCH after hospital discharge reduced mortality rates, but only when it was followed by a long-term health care plan, thus ensuring continuity of care for elderly participants.
authors.affiliation: Department of Public Health, Catholic University of Sacred Heart, Largo F. Vito 1, Rome, Lazio, Italy. gdamiani@rm.unicatt.it
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Damiani
authors.forename: Bruno
authors.initials: B
authors.lastname: Federico
authors.forename: Antonella
authors.initials: A
authors.lastname: Venditti
authors.forename: Lorella
authors.initials: L
authors.lastname: Sicuro
authors.forename: Silvia
authors.initials: S
authors.lastname: Rinaldi
authors.forename: Franco
authors.initials: F
authors.lastname: Cirio
authors.forename: Cristiana
authors.initials: C
authors.lastname: Pregno
authors.forename: Walter
authors.initials: W
authors.lastname: Ricciardi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003266:Continuity of Patient Care; D005260:Female; D006699:Home Care Services / Q000706:statistics & numerical data*; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009026:Mortality / Q000639:trends*; D010351:Patient Discharge; D010359:Patient Readmission; D016016:Proportional Hazards Models; D012189:Retrospective Studies