30-day hospital readmission of older adults using care transitions after hospitalization: a pilot prospective cohort study

Abstract

PurposePatients leaving the hospital are at increased risk of functional decline and hospital readmission. The Employee and Community Health service at Mayo Clinic in Rochester developed a care transition program (CTP) to provide home-based care services for medically complex patients. The study objective was to determine the relationship between CTP use, 30-day hospital readmission, and Emergency Room (ER) visits for adults over 60 years with high Elder Risk Assessment scores.Patients and methodsThis was a pilot prospective cohort study that included 20 patients that used the CTP and 20 patients discharged from the hospital without using the CTP. The medically complex study patients were drawn from the department of Employee and Community Health population between October 14, 2011 and September 27, 2012. The primary outcomes were 30-day hospital readmission or ER visit after discharge from the hospital. The secondary outcomes were within-group changes in grip strength, gait speed, and quality of life (QOL). Patients underwent two study visits, one at baseline and one at 30 days postbaseline. The primary analysis included time-to-event from baseline to rehospitalization or ER visit. Paired t-tests were used for secondary outcomes, with continuous scores.ResultsOf the 40 patients enrolled, 36 completed all study visits. The 30-day hospital readmission rates for usual care patients were 10.5% compared with no readmissions for CTP patients. There were 31.6% ER visits in the UC group and 11.8% in the CTP group (P = 0.37). The secondary analysis showed some improvement in physical QOL scores (pre: 32.7; post: 39.4) for the CTP participants (P < 0.01) and no differences in gait speed or grip strength.ConclusionBased on this pilot study of care transition, we found nonsignificant lower hospital and ER utilization rates and improved physical QOL scores for patients in the CTP group. However, the data leads us to recommend future studies with larger sample sizes (N = 250).

Health Care Outcomes and Advance Care Planning in Older Adults Who Receive Home-Based Palliative Care: A Pilot Cohort Study

“…This is a combined internal medicine and family medicine practice with several sites in the Rochester area. 10 This study was approved by the Mayo Clinic's institutional review board. Control group.…”

“…Promising results have surfaced, including reductions in ER visits, 30-day readmission rates, skilled nursing placement, inpatient length of stay, improved quality of life, and patient satisfaction. [8][9][10] It is important to identify the key elements to these services that have brought such successful results. This remains underinvestigated in the literature.…”

Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population

“…Our initial prospective cohort pilot comprised of 40 subjects demonstrated the feasibility of the program and allowed for normalization of the intervention. 11 However, the short-term and long-term effectiveness of this intervention was not firmly established. Such information will be essential to ensure that additional healthcare resources are achieving the expected outcomes.…”

Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada

“…La asociación con hospitalizaciones anteriores también se ha discutido previamente. Esta relación suele ser circular: padecer fragilidad predispone a sufrir mayor un número de eventos adversos, lo que incrementa el riesgo de hospitalizaciones y éstas, a su vez, se asocian a deterioro cognitivo y fisiológico, en particular en adultos mayores, lo que incrementa el riesgo de fragilidad [24][25][26][27] . En nuestro estudio, los adultos mayores frá-giles presentan un deterioro significativo de su calidad de vida, similar a lo comunicado por otros autores [28][29][30] .…”