Case finding and referral model for emergency department elders: a randomized clinical trial

STUDY OBJECTIVE: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.     

Characteristics and outcomes of older adults with community-acquired pneumococcal bacteremia

OBJECTIVES: To describe baseline characteristics and clinical outcomes of older adults with pneumococcal bacteremia, compare the frequency of serious outcomes according to pneumococcal vaccination status, and assess factors associated with mortality. DESIGN: Population-based case-series. SETTING: Group Health Cooperative, a health maintenance organization in Washington State. PARTICIPANTS: Community-dwelling adults aged 65 and older with a first episode of pneumococcal bacteremia between 1988 and 2002. MEASUREMENTS: Demographic characteristics, underlying medical conditions, vaccination status, and clinical outcomes, including death, hospitalization, length of hospital stay, and postdischarge care, were assessed using chart review. RESULTS: The mean age of the 200 elderly patients with pneumococcal bacteremia was 78; 61% were female. Forty percent had had chart-documented pneumococcal vaccination before the onset of bacteremia. The spectrum of clinical severity and consequences was broad. Ten percent were treated as outpatients. Of the 90% who were hospitalized, 16% were admitted to the intensive care unit. All-cause mortality at 30 days was 11%. Of survivors, 23% were discharged with home services, and another 20% were discharged to a nursing home. After controlling for age, sex, and pneumococcal vaccination status, predictors of death included coronary artery disease (odds ratio (OR)=4.6, 95% confidence interval (CI)=1.4-14.5) and immunocompromising conditions (OR=5.0, 95% CI=1.6-15.7). Outcomes were similar in patients who did and did not receive pneumococcal vaccination. CONCLUSION: In this elderly group, pneumococcal bacteremia was associated with substantial morbidity, mortality, and loss of independence. Coronary artery disease and immunocompromising conditions were independent predictors of death.     

Delivery of outpatient cardiac rehabilitation in a managed care organization

PURPOSE: This study aimed to assess referral and enrollment rates for postdischarge outpatient cardiac rehabilitation in a managed care organization. METHODS: A prospective cohort study investigated Atlanta area managed care members, age 30 years or older, hospitalized for acute myocardial infarction or coronary revascularization during 1997-1999. Postdischarge cardiology medical records were abstracted for evidence of postdischarge visits; counseling on diet, weight, or exercise; and referral to outpatient cardiac rehabilitation. Enrollment in outpatient cardiac rehabilitation was confirmed by chart abstraction. Referral and enrollment rates were estimated using logistic regression models. RESULTS: Of the 945 hospitalized patients, 783 remained alive and enrolled in the managed care organization 12 months after discharge. Of these 783 patients, 73.8% had at least one postdischarge cardiologist visit. Among these, 24.4% were referred by a cardiologist to outpatient cardiac rehabilitation, and 7.1% enrolled. Enrollment was significantly higher among patients with a documented referral than among patients not referred (P <.05). Patients 65 years of age or older were significantly less likely than younger patients to be referred to cardiac rehabilitation and enroll (P<.05). Of the patients with a postdischarge cardiologist visit, 31.5% received counseling on diet, weight, or exercise. The men and the patients with a body mass index of at least 30 were more likely to receive this counseling than women and those with body mass index less than 30 (P <.05). CONCLUSIONS: The low rates of referral and enrollment for postdischarge outpatient cardiac rehabilitation in this managed care population are consistent with rates observed at academic medical centers. Despite demonstrated benefits after acute coronary events, outpatient cardiac rehabilitation remains underused.     

Effect of a nurse team coordinator on outcomes for hospitalized medicine patients

PURPOSE: Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference. METHODS: In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease. RESULTS: A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052). CONCLUSION: The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety.     

Inpatient to outpatient transfer of care in urban patients with diabetes: patterns and determinants of immediate postdischarge follow-up

BACKGROUND: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus. METHODS: Retrospective study of 658 inpatients of a municipal hospital. Primary data sources were inpatient surveys and electronic records. RESULTS: Patients were stratified into outpatient follow-up (69%), acute care follow-up (15%), and those with no follow-up (16%); differences between groups were detected for age (P =.02), percentage discharged with insulin (P =.03), and percentage receiving a full discount for care (P<.001). Among patients with a postdischarge visit, 43% were seen in our specialty diabetes clinic, and 26% in a primary care site. Adjusted analyses showed any follow-up visit significantly decreased with having to pay for care. The odds of coming to the Diabetes Clinic increased if patients were discharged with insulin, had new-onset diabetes, or had a direct referral. CONCLUSIONS: In this patient cohort, most individuals accomplished a postdischarge visit, but a substantial percentage had an acute care visit or no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.     

Clinicians' predictions of nursing home placement for hospitalized patients.

Identifying patients who will need long-term care may improve the efficiency and effectiveness of acute hospital care. This prospective study evaluated clinicians' ability to identify patients requiring nursing home care. The study had two principal objectives. The first objective was to measure whether registered nurses, physicians, and social workers made similar estimates of the probability of nursing home placement early in an acute care hospitalization. The second objective was to identify the clinical characteristics of patients for whom the clinicians incorrectly predicted that they would return home. The study subjects were 342 patients older than age 55 who were admitted to the medicine, surgery, and neurology services of two university-affiliated Veterans Affairs hospitals. Fifteen percent were discharged to nursing homes. The nurses, physicians, and social workers had high agreement in their estimates of the probability of nursing home placement for each patient. However, each of the provider groups assigned low probability estimates to more than 20% of the patients discharged to nursing homes. Examination of the characteristics of patients assigned low probability estimates revealed that mental impairment and functional disability were higher in those patients who ultimately were discharged to nursing homes than in those patients who returned to their homes. These findings suggest that better assessment and interpretation of patient characteristics early in the hospital stay may improve discharge planning. Some clinicians appear to underestimate mental and functional impairment as risk factors for long-term care needs.     

Specialty-related disparities of readmission in patients with chronic heart failure: the importance of hospital-clinic cooperation.

OBJECT: The purpose of this study was to elucidate differences in readmission rates and late outcome in outpatients with chronic heart failure treated in different clinical settings. PATIENTS AND METHODS: This study included 65 consecutive patients who were admitted to our CCU due to acute heart failure for the first time and discharged from our institution. After their discharge, 31 were cared for by a cardiologist in the outpatient clinic of our institution (group A) and the other 34 were cared for by a general practitioner in a clinic (group B). The various findings during the acute phase and the follow-up period were retrospectively compared between the two groups. In addition, the incidence of unexpected readmission and prolonged outcomes were compared between the two groups. RESULTS: The patients in group B were older than those in group A, but no other differences were noted in patient characteristics. More patients in group A required more than one hospitalization within 6 months from discharge (group A, 35.5%; group B, 8.9%, p<0.01; follow-up period, 17.1+/-5.9 months). There was no difference in the survival rate between the groups. CONCLUSION: We concluded that stabilized outpatients should receive comprehensive care from a general practitioner to avoid the need for readmission after discharge.     

Consequences of preventing delirium in hospitalized older adults on nursing home costs

OBJECTIVES: To determine whether costs of long-term nursing home (NH) care for patients who received a multicomponent targeted intervention (MTI) to prevent delirium while hospitalized were less than for those who did not receive the intervention. DESIGN: Longitudinal follow-up from a randomized trial. SETTING: Posthospital discharge settings: community-based care and NHs. PARTICIPANTS: Eight hundred one hospitalized patients aged 70 and older. MEASUREMENTS: Patients were followed for 1 year after discharge, and measures of NH service use and costs were constructed. Total long-term NH costs were estimated using a two-part regression model and compared across intervention and control groups. RESULTS: Of the 400 patients in the intervention group and 401 patients in the matched control group, 153 (38%) and 148 (37%), respectively, were admitted to a NH during the year, and 54 (13%) and 51 (13%), respectively, were long-term NH patients. The MTI had no effect on the likelihood of receiving long-term NH care, but of patients receiving long-term NH care, those in the MTI group had significantly lower total costs, shorter length of stay and lower cost per survival day. Adjusted total costs were $50,881 per long-term NH patient in the MTI group and $60,327 in the control group, a savings of 15.7% (P=.01). CONCLUSION: Active methods to prevent delirium are associated with a 15.7% decrease in long-term NH costs. Shorter length of stay of patients receiving long-term NH services was the primary source of these savings.     

Level of care and complications among geriatric patients discharged from the medical service of a teaching hospital

To assess the effects of hospitalization on the subsequent placement and supportive care of elderly patients, the medical records of 233 consecutive patients aged 75 years or older, admitted to the medical service of a university hospital, were reviewed. The level of care on admission and at discharge, hospital-associated complications, and demographic data were abstracted for each patient. At discharge, 1 per cent returned to a nursing home, 6 per cent were newly placed in a nursing home, 65 per cent returned to the same level of care as on admission, 10 per cent returned home with an increased level of care, and 18 per cent died or were discharged to another acute care facility. Complications occurred in 30 per cent of patients but did not correlate with age, increased level of care at discharge, or increased rate of nursing home placement. Few elderly patients were discharged to nursing homes, and most returned home without arrangements for increased care.     

Older adults discharged from the hospital with delirium: 1-year outcomes

OBJECTIVES: To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital. DESIGN: Secondary analysis of prospective cohort data from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000. PARTICIPANTS: Four hundred thirty-three patients aged 70 and older who were not delirious at admission. MEASUREMENTS: Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1-year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60-4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43). CONCLUSION: Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1-year follow-up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.     

Characteristics of patients hospitalized with acute decompensated heart failure who are referred for hospice care

BACKGROUND: Hospice is a potential option for patients with end-stage heart failure whose symptoms and clinical status have progressed despite maximal medical therapy. However, little is known about hospice referral practices when patients are admitted because of acute decompensated heart failure. METHODS: Data from the Acute Decompensated Heart Failure Registry (ADHERE) were analyzed from October 1, 2001, to December 31, 2005, accounting for 182 898 patient episodes with known disposition from 307 hospitals. Demographic data, clinical characteristics, and medical management were compared in the group discharged to hospice vs patients discharged to home or to intermediate-care facilities. Hospitals, stratified by frequency of discharge of patients to hospice, were evaluated for adherence to performance measures. Temporal trends according to discharge category were analyzed using analysis of variance, and predictors of hospice referral were determined by multivariate analysis. RESULTS: The hospice cohort composed 1.6% (n = 3010) of the total sample. Patients referred to hospice were generally older, more likely to have been admitted because of antecedent heart failure in the preceding 6 months, more likely to receive intravenous inotropic therapy, less likely to receive angiotensin-converting enzyme inhibitors, and less likely to undergo a procedure (eg, dialysis or cardiac catheterization) during the hospitalization. The median rate of hospice referral increased from 0.8% in 2001 to 1.3% in 2005 (P < .008). Hospitals in the upper quartile of hospice referrals had comparable or higher rates of adherence to quality indicators for heart failure than did hospitals in the lowest quartile. Variables obtained at admission that were associated with hospice referral included older age (per 10-year increment; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), lower serum sodium concentration (per 5-mEq/L [to convert to millimoles per liter, multiply by 1.0] increment; OR, 0.81; 95% CI, 0.78-0.83), lower systolic blood pressure (per 10-mm Hg increment; OR, 0.86; 95% CI, 0.85-0.88), higher serum urea nitrogen concentration (per 10-mg/dL to convert to millimoles per liter, multiply by 0.375] increment; OR, 1.20; 95% CI, 1.18-1.21), and absence of lipid-lowering drug therapy (use of drug OR, 0.69; 95% CI, 0.63-0.75). CONCLUSIONS: A small percentage of patients admitted to acute care hospitals with decompensated heart failure are referred to hospice at rates increasing with time. Hospitals that refer patients to hospice are more likely to be in compliance with heart failure performance measures. Further investigation is required to determine if the hospice option is appropriately selected and if it should be offered to a broader cohort of patients.     

The effectiveness of an organized emergency department follow-up system

Half the patients discharged home from our emergency department with the diagnoses of acute infection, cervicolumbar strain, bronchospasm, allergic reaction, headache, syncope, vaginal hemorrhage, and undiagnosed chest/abdominal pain were randomly assigned to receive a follow-up telephone call two to three days after their visit. Patients in the follow-up call group were telephoned by an ED nurse who questioned them about changes in their clinical status and clarified the aftercare and referral instructions received during the ED visit. Seven days after the visit, a questionnaire that rated patient satisfaction about six aspects of the ED visit was sent to those patients who had been contacted successfully (study group), and to a diagnosis-matched group of patients (control) who did not receive a follow-up call. A nurse was able to reach 144 of the 297 patients assigned to the study group. Significant referral and aftercare interventions were made in 53 (37%) cases including three patients who were instructed to return to the ED. Questionnaires were returned by 83 of 144 (49%) of the study group and by 94 of 262 (35%) of the control group. Male study group patients consistently rated five of six aspects of their visit higher than did the male controls. No difference was observed in questionnaire ratings between the female study and control groups. We conclude that male patients reached by a follow-up telephone call have a more positive perception of their ED visit. A follow-up call also can be useful for reinforcing aftercare instructions, follow-up referrals, and problem-patient identification.     

A prediction rule for the use of postdischarge medical services

OBJECTIVE: To develop and validate a prediction rule screening instrument, easily incorporated into the routine hospital admission assessment, that could facilitate discharge planning by identifying patients at the time of admission who are most likely to need postdischarge medical services. DESIGN: Prospective cohort study with separate phases for prediction rule development and validation. SETTING: Urban teaching hospital. PATIENTS/PARTICIPANTS: General medical service patients, 381 in the derivation phase and 323 in the validation phase, who provided self-reported medical history, health status, and demographic data as a part of their admission nursing assessment, and were subsequently discharged alive. MEASUREMENTS AND MAIN RESULTS: Use of postdischarge medical services such as visiting nurse or physical therapy, medical equipment, or placement in a rehabilitation or long-term care facility was determined. A prediction rule based on a patient’s age and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) physical function and social function scores stratified patients with regard to their risk of using postdischarge medical services. In the validation set, the rate of actual postdischarge medical service use was 15% (15 of 97), 36% (39 of 107), and 58% (57 of 98) among patients characterized by the prediction rule as being at “low”, “intermediate,” and “high” risk of using postdischarge medical services, respectively. CONCLUSIONS: This prediction rule stratified general medical patients with regard to their likelihood of needing discharge planning to arrange for postdischarge medical services. Further research is necessary to determine whether prospective identification of patients likely to need discharge planning will make the hospital discharge planning process more efficient. Presented at the Society of General Internal Medicine annual meeting, April 1994.     

A specialized home care intervention improves survival among older post-surgical cancer patients

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.     

Age-related differences in care receipt and symptom experience of elderly cancer patients dying at home: Lessons from the DEATH project

Background:   Data on the differences between older and younger elderly cancer patients dying at home is sparse. To clarify age-related differences in symptom experience and care receipt of elderly cancer patients at end-of-life, we conducted a subanalysis study of the Dying Elderly at Home (DEATH) project, a multicenter study of 240 elderly aged 65 and older dying at home.
Methods:   We assessed the frequency of symptom experience and end-of-life care receipt in home elderly patients during the last 2 days of their lives and evaluated the differences between younger elderly (aged 65–74) and older elderly (aged 75+) cancer decedents. The general practitioners were asked to fill out a questionnaire immediately after the death of study patients. A total of 66 younger and 51 older elderly cancer decedents were included in the analysis.
Results:   Coma and dementia were common among younger and older elderly patients. Older decedents were less likely to experience anxiety, but, after adjustment for baseline characteristics, this age-related difference did not clearly appear. Older decedents were also less likely to receive opioids than younger decedents. There were no significant differences in volume of i.v. hydration between the two groups.
Conclusions:   Our results suggested that there were no differences in symptom experience and care receipt among older and younger decedents, except in opioid use, at end-of-life. These findings imply a similar need of end-of-life care for younger and older elderly cancer patients who opt for home death.     

Effectiveness of a National Transitional Care Program in Reducing Acute Care Use

This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals' conditions, effectively articulate their preferences, and enable self‐management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score‐based weighting. Participant and caregiver surveys on quality of life and self‐rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score–adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5–0.6) and 0.81 (95% CI = 0.72–0.90) 30 days after discharge and 0.6 (95% CI = 0.6–0.7) and 0.90 (95% CI = 0.82–0.99) 180 days after discharge. Quality of life and self‐rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.