| Primary Author: | Mary Elizabeth Mather, MSN |
| Co-Principal Investigators/Collaborators: | Dr. Taral Patel, Dr, Sara Espinoza, ACOS, GRECC |
| Organization | South Texas Veterans Healthcare System |
Abstract
Purpose
The goal of this quality improvement project was to improve transitions to home by contacting patients during this high risk window in order to increase safety awareness, improve medication compliance, and prevent readmission.
Background
It is estimated that 20% of Medicare beneficiaries experience readmission after hospital discharge (DC), and studies show that often readmission is avoidable. Follow-up (FU) is usually scheduled 7-10 days after DC while the high risk time for post-DC complications, such as falls, is within 24-72 hrs after DC.
Materials & Methods
Patients were outpatient veterans enrolled in the Geriatric Evaluation and Management clinic at Audie Murphy VA Hospital. Scripted follow up calls were made 24-72 hrs post-DC over a 15-month period by a clinical nurse leader (CNL), who inquired about the ability of the patient to care for himself, new disability, new medications, social work (SW) issues, and FU. Unmet needs were promptly addressed and appropriate FU planned.
Results
96 patients were called; medical comorbidity was common: 65.4% had 2 or more of diabetes, congestive heart failure, chronic obstructive pulmonary disease, and hypertension. 73.9% of patients received new medications upon DC, and 16.7% had a new disability. While most (88.1%) were taking medications appropriately, 4.8% were taking the wrong medication or dose. 12.1% of encounters resulted in intervention by the GEM physician, 4.8% experienced a fall after DC and 15.3% were readmitted within 1 month. Neither falls nor readmissions were associated with any specific chronic disease.
Conclusion
The GEM team identified the need for post DC FU calls to improve communication with patients and address unmet needs. Anecdotally, patients reported increased satisfaction and reduced anxiety transitioning to home post DC as a result of this intervention; however, this was not formally evaluated. Patients and their families should receive disease and safety education, particularly with regard to falls, at every encounter.
Bibliography
Bowers, J. Breaking the fall: Preventing fractures after discharge. January ACP Hospitalist, 2009.
Davenport, R. D., Vaidean, G. D., Jones, C. B., Chandler, A. M., Kessler, L. A., Mion, L. C., Shorr, R. I. Falls following discharge after an in-hospital fall. BMC Geriatrics 2009, 9:53.
Sherrington, C., Lord, S., Vogler, C., Close, J., Howard, K., Dean, C., Clemson, L., Barraclough, E., Ramsay, E., O’Rourke, S., Cumming, R. Minimizing disability and falls in older people through a post-hospital exercise program: a protocol for a randomized controlled trial and economic evaluation. BMC Geriatrics 2009, 9:8
© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).