Transitional care helps elderly with heart failure

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Specialized “transitional” nursing care that helps elderly heart failure patients move from hospital to home may cut their risk of death or hospital readmission, a new study shows.

The program, tried out at six Philadelphia hospitals, also boosted patients’ quality of life for the three months it was provided, according to findings published in the Journal of the American Geriatrics Society. 

In the study, 239 older adults hospitalized because of heart failure received either routine treatment or transitional care. In addition to standard hospital care, the latter group received visits from an advanced practice nurse (APN)—a nurse with a master’s degree—every day while in the hospital, and then regular home visits for the three months after hospital discharge. APNs were also available over the phone seven days a week.

These nurses acted as a “point person” for patients and their families, coordinating their care from the hospital to the first few months at home, the study’s lead author, Dr. Mary Naylor, told Reuters Health.

According to Naylor, a registered nurse and professor of nursing at the University of Pennsylvania in Philadelphia, a prime goal is to help patients and their families better manage their health, and know when they’re “running into trouble” and need help.

Another focus, she said, is to help elderly heart failure patients—who typically have several other health conditions, such as diabetes, High Blood Pressure and depression—meet their personal goals, whether it’s spending time gardening or going to a grandchild’s graduation.

In their study, Naylor and her colleagues found that patients who received this care were less likely to die or to have to return to the hospital over the next year. Nearly 45 percent of these patients were alive and had stayed out of the hospital one year later, while the same was true of only 32 percent in the routine-care group.

Elderly adults with heart failure have the highest rate of hospitalization of any adult patient group, as well as yearly health care expenses that top $24 billion, Naylor and her colleagues note in their report.

The researchers found that although transitional care added to patients’ initial hospital costs, it saved money in the long run. Because these patients had fewer hospitalizations and emergency room and doctor visits, their health care costs for the year were nearly 38 percent lower, according to the report.

While routine care for heart failure in this study and in real-life settings often includes home health services, the transitional care program had a particular focus on smoothing the move from hospital to home.

In the U.S. health system, Naylor explained, standard care is organized into “separate and distinct silos” such as hospitals and home health agencies. In this study, she noted, the same nurse who designed a patient’s hospital discharge plan made sure it was implemented at home, substituting for traditional visiting nurse care.

This type of care has typically not been used, according to Naylor, because of both the health system’s disjointed structure and a lack of Medicare reimbursement. Based on these findings, though, a major health insurer is now set to launch a pilot program modeled on the study in Pennsylvania, New Jersey and Delaware.

SOURCE: Journal of the American Geriatrics Society, May 2004.

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