title: Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.
abstract: OBJECTIVE
  To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality.
  
  
  METHODS
  Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs. All patients received a follow-up call at 30 days post discharge to assess psychosocial needs, patient and caregiver stress, and physician follow-up.
  
  
  RESULTS
  83.3% of intervention group participants experienced significant barriers to care. For 73.3% of this group, problems did not emerge until after discharge. Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post discharge. There were no differences between groups on patient or caregiver stress or hospital readmission.
  
  
  CONCLUSIONS
  At-risk older adults may benefit from transitional care programs to ensure delivery of care as ordered and address unmet needs. Although patients who received the intervention were more likely to communicate and follow up with their physicians, the absence of impact on readmission suggests that more intensive efforts may be indicated to affect this outcome.
authors.affiliation: Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St. m/c 923, Chicago, IL 60612, USA. saltfeld@uic.edu
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Altfeld
authors.forename: Gayle E
authors.initials: GE
authors.lastname: Shier
authors.forename: Madeleine
authors.initials: M
authors.lastname: Rooney
authors.forename: Tricia J
authors.initials: TJ
authors.lastname: Johnson
authors.forename: Robyn L
authors.initials: RL
authors.lastname: Golden
authors.forename: Kelly
authors.initials: K
authors.lastname: Karavolos
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Avery
authors.forename: Vijay
authors.initials: V
authors.lastname: Nandi
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Perry
mesh_terms: D000369:Aged, 80 and over / Q000523:psychology*; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D003695:Delivery of Health Care / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006301:Health Services Needs and Demand; D006699:Home Care Services / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D010347:Patient Care Planning; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D015397:Program Evaluation; D013315:Stress, Psychological; D013689:Telephone; D013997:Time Factors