Preventing 30-Day Rehospitalization Among Elderly Patients Through A Collaborative Transition of Care Program Between Acute and Primary Care

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Wingate, K. (2016). Preventing 30-Day Rehospitalization Among Elderly Patients Through A Collaborative Transition of Care Program Between Acute and Primary Care. Unc Charlotte Electronic Theses And Dissertations.
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Abstract

There is a disconnect between acute and primary care when transitioning elderly patients from the hospital to the community, often leading to insufficient primary care follow-up and increased rehospitalization. The purpose of this pilot study was to examine the effect of a multi-component transition of care intervention coordinated by the primary care setting on 30-day rehospitalization and primary-care follow-up rates, as well as to examine the implementation of the intervention into practice. Thirty-day outcomes were measured by telephone interview and electronic record review of 10 elderly participants who were discharged from a local hospital and received the multi-component transition of care intervention led by an adult-gerontological primary care nurse practitioner. Of the 10 participants who completed all phases of the intervention and lived to 30-days post-discharge, none had a 30-day rehospitalization. The intervention may be effective in preventing 30-day rehospitalization. Completing post-hospital follow-up appointments was more efficient than those completed prior to implementation because the nurse practitioner had already met with participants during their hospital stay to gather information on the hospitalization and begin discharge planning. The intervention required a proactive approach from the primary care office to obtain hospitalization information, and was found to be time intensive, yet effective, among this group of participants. Further research is needed with a larger sample size and a longer duration of follow-up.

Details
Author

Wingate, Katie

Title

Preventing 30-Day Rehospitalization Among Elderly Patients Through A Collaborative Transition of Care Program Between Acute and Primary Care

Physical Description

1 online resource (61 pages) : PDF

Date

2016

Degree Granting Institution

University of North Carolina at Charlotte

Abstract

There is a disconnect between acute and primary care when transitioning elderly patients from the hospital to the community, often leading to insufficient primary care follow-up and increased rehospitalization. The purpose of this pilot study was to examine the effect of a multi-component transition of care intervention coordinated by the primary care setting on 30-day rehospitalization and primary-care follow-up rates, as well as to examine the implementation of the intervention into practice. Thirty-day outcomes were measured by telephone interview and electronic record review of 10 elderly participants who were discharged from a local hospital and received the multi-component transition of care intervention led by an adult-gerontological primary care nurse practitioner. Of the 10 participants who completed all phases of the intervention and lived to 30-days post-discharge, none had a 30-day rehospitalization. The intervention may be effective in preventing 30-day rehospitalization. Completing post-hospital follow-up appointments was more efficient than those completed prior to implementation because the nurse practitioner had already met with participants during their hospital stay to gather information on the hospitalization and begin discharge planning. The intervention required a proactive approach from the primary care office to obtain hospitalization information, and was found to be time intensive, yet effective, among this group of participants. Further research is needed with a larger sample size and a longer duration of follow-up.

Genre

doctoral dissertations

Subjects--Topics

Nursing
Medicine
Gerontology

Degree

D.N.P.

Keywords

Medicare
Primary Care
Readmission
Rehospitalization
Transition of Care

Subject Area

Health Services Research

Advisor(s)

Woods, Stephanie

Committee Members

Whitaker-Brown, Charlene
Kelly, William
Lamorey, Suzanne

Degree Note

Thesis (D.N.P.)--University of North Carolina at Charlotte, 2016.

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Rights Holder Information

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Identifier

Wingate_uncc_0694D_11028

Permalink

http://hdl.handle.net/20.500.13093/etd:248