Enhanced discharge planning for hospitalized older adults: A randomized trial

Objectives:The purpose of this study was to identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions and mortality. Methods: Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone based Enhanced Discharge Planning Program (EDPP) intervention which included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs. All patients received a follow-up call at 30 days post discharge to assess psychosocial needs, patient and caregiver stress and physician follow-up. Results: 83.3% of intervention group participants experienced significant barriers to care. For 73.3% of this group, problems did not emerge until after discharge. Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post-discharge. At 30 days post-discharge, mortality was 2.2% in the intervention group and 5.3% in the control group. There was no difference between groups on patient or caregiver stress or hospital readmission. Conclusions: At risk older adults may benefit from transitional care programs to ensure delivery of care as ordered and address unmet needs. While patients who received the intervention were more likely to follow-up with their physicians and experienced decreased mortality, the lack of impact on readmission suggests that additional efforts may be necessary to affect this outcome.