Morrison Jessica, Palumbo Mary Val, Rambur Betty
Kappa Tau, Support and Services at Home (SASH) Wellness Nurse, Cathedral Square Corporation, S. Burlington, VT, USA.
Associate Professor, Department of Nursing, University of Vermont, Burlington, VT, USA.
J Nurs Scholarsh. 2016 May;48(3):322-9. doi: 10.1111/jnu.12210. Epub 2016 Apr 13.
Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of health care through temporary follow-up after hospital discharge. This study describes the approaches and outcomes of two distinct transitional care programs serving different populations: one is provided by master's-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPCs). Existing research has shown that transitional care programs with intensive follow-up reduce hospitalizations, emergency department (ED) visits, and costs. Few studies, however, have included side-by-side descriptions of the efficacy of transitional care programs varying by healthcare providers or program focus.
This is a retrospective cohort study comparing the number of ED visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included differences in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program (September 2014 to December 2014) were analyzed (n = 98). The average age of participants was 69 years and 65% were female. Data were collected from patients from the PPC program from September 2014 to April 2015 (n = 71). Thirty participants died within 120 days after the intervention and were excluded; the remaining 41 were included in the analysis. Participants had an average age of 81 years and 63% were female.
For the CNS program, a secondary analysis of existing data was performed. For the PPC program, a review of patient charts was done to collect data on encounters. A Wilcoxon matched-pairs signed-rank test was performed to test for significance.
Patients in the CNS intervention had significantly fewer ED visits (p < .005) and hospitalizations (p < .005) in the 4 months after the intervention than in the 4 months before the intervention. Patients in the PPC program had a nonsignificant reduction in ED visits (p = .327) and a significant reduction in hospitalizations postintervention (p = .03).
Both transitional programs have value in decreasing rehospitalizations. The CNS intervention also significantly reduced ED visits for their target population. Further study with randomized controlled trials is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed.
Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.
过渡性护理是一种新兴的医疗保健模式，旨在通过出院后的临时随访减少可预防的不良事件及相关医疗保健的使用。本研究描述了为不同人群提供服务的两个不同过渡性护理项目的方法和结果：一个由专注于慢性病自我管理的硕士学历临床护士专家（CNS）提供，另一个由专门从事姑息治疗的医生（PPC）提供。现有研究表明，强化随访的过渡性护理项目可减少住院、急诊就诊次数及费用。然而，很少有研究同时描述不同医疗服务提供者或项目重点的过渡性护理项目的疗效。
这是一项回顾性队列研究，比较了每个过渡性护理项目中患者在干预前后120天内的急诊就诊次数和住院次数。每个项目都包括出院后家访，但在项目重点（慢性病与姑息治疗）、评估和干预以及人群（农村与城市）方面存在差异。对CNS项目参与者（2014年9月至2014年12月）的数据进行了分析（n = 98）。参与者的平均年龄为69岁，65%为女性。收集了2014年9月至2015年4月PPC项目患者的数据（n = 71）。30名参与者在干预后120天内死亡并被排除；其余41名被纳入分析。参与者的平均年龄为81岁，63%为女性。
对于CNS项目，对现有数据进行了二次分析。对于PPC项目，查阅了患者病历以收集就诊数据。进行了Wilcoxon配对符号秩检验以检验显著性。
CNS干预组患者在干预后4个月内的急诊就诊次数（p <.005）和住院次数（p <.005）显著少于干预前4个月。PPC项目患者的急诊就诊次数减少不显著（p =.327），干预后住院次数显著减少（p =.03）。
两个过渡性项目在减少再次住院方面都有价值。CNS干预还显著减少了其目标人群的急诊就诊次数。需要进行随机对照试验的进一步研究，以便更好地了解最适合改善过渡性护理结果的医疗保健人员。还需要进行未来研究以检查每种干预措施的成本节约情况。
过渡性护理项目有可能在患者易发生不良事件和不良结局的关键过渡时期预防不必要的医疗保健使用。
