Effectiveness of a Nurse-Managed Follow-Up Program for Rehabilitation Patients After Discharge

Authors

  • Susan M. Rawl PhD RN,

    Corresponding author
      School of Nursing, Indiana University, 1111 Middle Drive, Indianapolis, IN 46202-5107
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    • Susan Rawl is an assistant scientist at Indiana University School of Nursing in Indianapolis; she was an associate professor in the department of nursing at Purdue University Calumet in Hammond, IN, when this research was conducted.

  • Kristen L. Easton MS RN CRRN,

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    • Kristen Easton is an assistant professor of nursing at Valparaiso University and a community health educator at Porter Memorial Hospital in Valparaiso, IN.

  • Sheila Kwiatkowski BSN RN,

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    • Sheila Kwiatkowski is a medical case manager and Donna Zemen is a nurse manager at St. Margaret Mercy Healthcare Centers in Hammond, IN.

  • Donna Zemen BSN RN CRRN CFNP,

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    • Sheila Kwiatkowski is a medical case manager and Donna Zemen is a nurse manager at St. Margaret Mercy Healthcare Centers in Hammond, IN.

  • Bernard Burczyk MS MBA

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    • Bernard Burczyk is a senior associate with EDO Seidman, CLP, in Chicago, IL.


School of Nursing, Indiana University, 1111 Middle Drive, Indianapolis, IN 46202-5107

Abstract

Former patients in a rehabilitation unit at a large Midwestern hospital continued to actively seek services provided by the inpatient nursing staff, primarily through telephone contact, long after their discharge. A proactive formal follow-up program managed by an advanced practice nurse in rehabilitation was proposed as a better means of providing continuing care for rehabilitation patients after discharge. To examine the efficacy of the nurse-managed follow-up program, a randomized clinical trial was conducted. One hundred patients were randomly assigned to either the intervention group or the control group. Comparisons were made between the two groups on several outcome measures at 4 months after discharge. Outcomes included Functional Independence Measure (FIM™) instrument scores, complication rates, rehospitalizations, and anxiety levels. The organizational outcomes included number and types of calls to staff, as well as time spent by staff nurses and social workers. The results indicated significant differences between the intervention and control groups in terms of anxiety levels, the number of calls made to the unit, and the amount of time spent by staff nurses and social workers.

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