Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial

OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.     

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

Objectives

To examine the effect of an emergency department (ED )‐based transitional care nurse (TCN ) on hospital use.

Design

Prospective observational cohort.

Setting

Three U.S. (NY , IL , NJ ) ED s from January 1, 2013, to June 30, 2015.

Participants

Individuals aged 65 and older in the ED (N = 57,287).

Intervention

The intervention was first TCN contact. Controls never saw a TCN during the study period.

Measurements

We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30‐day admission (any admission on Days 0–30) and 72‐hour ED revisits.

Results

A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: ?9.9% risk of inpatient admission, 95% confidence interval (CI ) = ?12.3% to ?7.5%; site 2: ?16.5%, 95% CI = ?18.7% to ?14.2%; site 3: ?4.7%, 95% CI = ?7.5% to ?2.0%). Participants with TCN contact had greater risk of a 72‐hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7–2.3%; site 2: 1.4%, 95% CI = 0.7–2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: ?7.8%, 95% CI = ?10.3% to ?5.3%; site 2: ?13.8%, 95% CI = ?16.1% to ?11.6%).

Conclusion

Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

     

Cost‐Effectiveness of a Barcelona Home Care Program for Individuals with Multimorbidity

To improve the efficiency and effectiveness of care and optimize healthcare resources, a home healthcare program was created for individuals with multiple chronic conditions. Demographic and clinical characteristics of the 261 individuals (mean age 84) included in the program from its inception in 2011 through 2013 (mean stay in the program 203 ± 192 days) were prospectively analyzed. The number of hospital admissions, length of stay, and costs for individuals admitted to the program were compared for two time periods: the 6 months before admission to the program and their stay in the program. After admission to the program, the number of hospital admissions and the hospital length of stay per person per month decreased from 0.36 ± 0.21 to 0.19 ± 0.52 (P < .001) and from 3.5 to 1 day (P < .001), respectively. Surveys of randomly selected patients and caregivers showed high satisfaction with the program. Costs per person per day decreased from €54.65 (US$73.12) to €17.91 (US$23.96), a reduction of 67.1%. Fewer admissions and shorter hospital stays enabled the hospital to eliminate five acute beds for every 50 individuals admitted to the program. In conclusion, home care for individuals with chronic illness with multimorbidity reduced the number of hospital admissions and length of stay, resulting in good patient satisfaction and lower costs.     

Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study

Background

As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction.

Methods

This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010–2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups.

Results

VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01–2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22–2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11–0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55–1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation.

Conclusions

The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

     

The University of California at Los Angeles Alzheimer's and Dementia Care Program for Comprehensive,Coordinated, Patient‐Centered Care: Preliminary Data

Dementia is a chronic disease that requires medical and social services to provide high‐quality care and prevent complications. As a result of time constraints in practice, lack of systems‐based approaches, and poor integration of community‐based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimer's and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient‐centered care for individuals with Alzheimer's disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around‐the‐clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimer's Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.