From hospital to home: a brief nurse practitioner intervention for vulnerable older adults.
A randomized controlled trial was conducted to evaluate the impact of a brief nurse practitioner (NP) intervention on care transitions among older hospitalized adults discharged to home (N = 199). Immediately following discharge, participants randomly assigned to the intervention received up to three home visits and two telephone calls from a registered NP that included medication review, care coordination, assessment of medical care needs, and brief coaching in self-management skills. Usual care participants received all standard medical care, including access to case management services. Intervention participants reported improved satisfaction with medical care (p = 0.008) and self-efficacy in managing medical conditions (p = 0.001) and had fewer primary care visits (p = 0.036) but no change in hospital readmissions at 6 months following enrollment. These findings suggest that intervening at the point of transition may extend the reach of the primary care physician by improving patient outcomes through nursing support at a high-risk period of care-the transition from hospital to home.
Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA. enguidan@usc.edu
Susan
S
Enguidanos
Nancy
N
Gibbs
Paula
P
Jamison
D000368:Aged; D003266:Continuity of Patient Care; D005260:Female; D006801:Humans; D008297:Male; D009722:Nurse Practitioners; D010351:Patient Discharge; D017060:Patient Satisfaction