Tuesday, July 28, 2009

Transitional Care Cuts Hospital Re-Entry Rates, Costs

The NPR story featuring Mary Naylor's Transitional Care Model is now available online at NPR.org:

Here's a number that tells you a lot about what's wrong with the American health care system: When older patients get discharged from a hospital, 1 out of 5 of them will come right back within a month. Medicare pays $17 billion a year on these hospital readmissions. And in many cases, coming back should have been avoidable.

Mary Naylor is trying to change that. She started the Transitional Care Model at the University of Pennsylvania Health Care System in Philadelphia. A nurse with advanced training in geriatrics is assigned to an elderly patient while he is in the hospital and then follows the patient, with frequent visits and contact, over two or three months to help him manage his own care.

"Every time an older adult is hospitalized, it generally results in changes in their plan of care," says Naylor. Some of the instructions from a doctor can be hard to follow, like new prescriptions. "So they would go home and 24 hours after discharge have a set of prescriptions, drugs already in their cabinet and wonder, 'Should I be taking these plus these?'"

For the rest of the story and to hear the clip from Morning Edition, click here.


The INQRI program is very invested in ensuring good patient care quality at each stage of the health care journey. An INQRI team at Marquette University has been working for the past two years on discharge preparation.

Hospital readmission and emergency department utilization within the first 30 days following hospital discharge represent adverse, potentially avoidable, and costly outcomes of hospitalization. For their project, "A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes," Marianne Weiss and Olga Yakusheva, worked on linking the unit-level nurse practice environment and nursing care processes with patient outcomes at discharge and post-hospitalization. Specifically, the study examined direct and indirect causal relationships between the nursing practice environment, the discharge teaching process and readiness for hospital discharge with hospital readmission and emergency department utilization.

Dr. Weiss has published extensively regarding discharge readiness. To read her article, "Patients' Perceptions of Hospital Discharge Informational Content," co-authored by Lynn Maloney, click here.

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