Department of Epidemiology, School of Public Health, Columbia University, New York, New York, USA.
J Am Geriatr Soc. 2011 Mar;59(3):544-51. doi: 10.1111/j.1532-5415.2010.03308.x.
Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.
居家的老年患者在住院期间以及出院回家或转至康复机构的过程中，可能无法得到最佳的护理。本为期两年的研究描述了一种护士从业者（NP）主导的过渡性护理方案，该方案嵌入现有的居家基础医疗保健（HBPC）项目中。该过渡性护理试点项目旨在通过缩短住院时间、降低住院费用以及更好地记录患者病情的复杂性，提高协调和护理连续性，减少再入院率，获得积极的医疗服务提供者反馈，并展示经济效益。采用前后设计，比较了干预前后的住院时间（LOS）、病例组合指数和与入院相关的财务成本。通过结构化的焦点小组，收集了住院和初级保健提供者对该方案的有用性和满意度的反馈。该方案改善了居家初级保健提供者与所有专科的住院提供者之间的沟通，并促进了关键患者信息的及时、准确传递。该干预措施并未显著降低住院患者的 LOS 和再入院率。虽然还需要进一步的研究，但该方案在经济方面的影响是令人安心的。这种由 NP 主导的方案模式可能有助于加强 HBPC 项目中老年人的住院管理和过渡性护理，并应考虑将其纳入 HBPC 护理模式。
