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Keywords:

  • transitional care;
  • older adults;
  • heart failure;
  • comorbid conditions;
  • rehospitalizations

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 χ2=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.