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Purpose of Study: This study describes a social-worker navigator transitional care model for at-risk seniors being discharged from hospital to home. The model is designed to prevent rehospitalizations so as to improve quality of life and patient outcomes. This model is different from others with its focus on the psychosocial aspects of care transitions, medical needs, and individualized needs with the provision of nonreimbursable services.
Primary Practice Setting: Care begins in the acute care hospital or inpatient rehabilitation facility and continues in the postdischarge home environment. Participants are connected to community services to support their independent living at home.
Methodology and Sample: Case managers, physicians, or others refer potential participants to the navigator. Criteria for inclusion include the following: age 65 years or older, Medicare and/or Medicaid recipient, living in the same county as the hospital, and having at least 2 of a list of 11 criteria that predict readmission. After the participant agrees to enroll, the navigator recommends in-home services at discharge. Within the first 72 hr, the navigator makes a home visit to evaluate the home environment, assess medical management, and make referrals for other services. Follow-up phone calls and other home visits are made by the navigator during the participant's enrollment, which is from 30 days to 4 months.
Results: Hospital readmissions were decreased by 61% for this high-risk population. Cost savings by preventing readmissions correlated to a cost savings of $628,202 per year. The 36-Item Short-Form Health Survey showed statistically significant improvements in quality-of-life scores for both physical and mental health summary scales and for all 8 subscales (p < .004). Almost all (99%) of respondents were satisfied with the overall Hospital to Home program.
Implications for Case Management Practice: The results of this study demonstrate the importance of extending social support and health education into the home after discharge from the hospital. Access to immediate in-home care services such as transportation, housekeeping, laundry, and light meal preparation allows patients not to experience gaps in care that could result in a readmission. The assigned navigator reinforces medical management and connects participants to appropriate community resources in order to remain safe at home.
Hospital readmission rates for the population aged 65 years and older within 30 days of a hospital discharge have received increased scrutiny as changes emerge in Medicare health care policy. According to a 2005 report by the Medicare Payment Advisory Commission, 17.6% of hospital admissions resulted in readmissions within 30 days of discharge. These readmissions, according to Medicare Payment Advisory Commission, accounted for $15 billion of Medicare spending.
According to Naylor et al. (2010), elderly patients are at increased risk for poor outcomes in the transition from hospital to home. Factors associated with poor outcomes include breakdowns in communication between providers across health care agencies, inadequate patient and caregiver education, poor continuity of care, and limited access to services. Furthermore, Brown-Williams (2006) asserts that because elders are released from the hospital after shorter stays and in weaker conditions, there is an even greater need for discharge planning and postdischarge services at home. Seniors at high risk for rehospitalization include those with multiple medical problems, functional deficits, cognitive impairment, depression, polypharmacy, and lack of social support.
A social worker is one appropriate transition navigator because this professional is trained in assessing home needs and accessing specialized community resources to support a safe and sustainable living environment after hospital discharge. The navigator needs to be comfortable with leaving the hospital to provide services in the client's home environment, thus providing a rich understanding of environmental barriers to recovery.
In a review of literature, four well-documented transitional care interventions were explored. The Transitional Care Model (Naylor et al., 2010), Project RED (Jack et al., 2009), the Care Transitions Intervention (Coleman et al., 2004), and BOOST (Society of Hospital Medicine, 2011) all serve the hospitalized older adult population with a goal of decreasing readmissions while maintaining a high level of patient satisfaction. Secondary goals common to all programs include increasing the patient's ability to self-manage health care and advocating for health needs through effective communication along the health care continuum.
However, there are several programmatic differences among these transition programs. Some programs are limited to hospital-based interventions and contact, whereas others follow the patient into the postdischarge environment. Another difference is the professional identified to provide the interventions. The Transitional Care Model and the Care Transitions Intervention provide advanced practice nurses and nurse transition coaches to coordinate and provide the interventions both in the hospital and after discharge. Home visits and follow-up phone calls are used by both these programs to provide education on disease management and to reinforce adherence to care plans (Coleman et al., 2004; Naylor et al., 2010). In contrast, Project RED and BOOST focus on the interdisciplinary hospital care team to implement the interventions (Jack et al., 2009; Society of Hospital Medicine, 2011).
Each of these models identified decreases 30-day readmission rates and emergency department (ED) visits or the number of days hospitalized. BOOST reported early data from six of 60 sites that the 30-day readmission rates decreased from 14.2% to 11.2% and a 21% reduction in 30-day all-cause readmission rates (Society of Hospital Medicine, 2011). Although data from the Transitional Care Model did not report 30-day readmission rates, the data reflected that at 24 weeks, control group patients experienced 760 days of hospitalization compared with 270 days for the intervention group (Naylor et al., 2010). In addition, the average length of stay for a readmitted patient in the control group was 11 days (+/-10.6 days) versus 7.5 days (+/-4.8 days) for the intervention group. In Coleman's 8-month study, 13.8% of control group patients were readmitted within 30 days versus 8.9% in the intervention group. Emergency department or observation unit visits within 30 days was 14.2% in the control group versus 11.0% in the intervention group (Coleman et al., 2004). Project RED data showed a 30% lower rate of hospital utilization in the intervention group within 30 days of discharge compared with patients who received the "usual care." Thirty-day hospital readmission rates and ED use rates decreased from 20% to 15% and from 24% to 16%, respectively (Jack et al., 2009).
While well-designed and successful, these programs did not intentionally focus on elders with a combination of complex social and medical needs. Frail elders are a specific population that are best identified using a multifactorial approach, including not only age and diagnosis, but also factors such as nutritional impairment, polypharmacy, and lack of social support. In addition, previous studies have primarily focused on outcome measures of financial concern, especially length of stay and readmission rates. While vitally important, quality-of-life measures are noticeably missing from these studies.
Furthermore, current transition programs may lack some of the necessary coordination and provision of postdischarge services, including instrumental activities of daily living (IADLs), to bridge the gap between discharge and initiation of community services. Transition programs that include short-term in-home services for transportation to doctor appointments and shopping, light housekeeping, meal preparation, and laundry may see further beneficial outcomes. These services are often not available at discharge and often increase the risk for readmission. A needs assessment of community services prior to initiation of this program revealed up to a 4-month enrollment period or waiting list for some of these services. A social worker is one appropriate transition navigator because this professional is trained in assessing home needs and accessing specialized community resources to support a safe and sustainable living environment after hospital discharge. The navigator needs to be comfortable with leaving the hospital to provide services in the client's home environment, thus providing a rich understanding of environmental barriers to recovery.
All of the participants were successfully discharged home, with 48% going home alone. Approximately 28% of participants required an ED visit postdischarge and 22% required hospital readmission for any cause. The hospital readmission rate of county residents aged 65 years and older in 2007 was 57%. This represents a 61% reduction in hospital readmissions and a cost savings of approximately $628,202 per year to the hospital.
Therefore, the purpose of this study was to evaluate the effectiveness of an innovative Hospital to Home transition program that utilizes a social worker navigator who identifies frail elders at risk for readmission during their hospitalization and follows them into their home environment. The navigator focuses not only on health-related needs but also on IADLs to ensure a successful transition. These program components are provided in addition to the patient and family/caregiver education and empowerment for care plan adherence that other programs provide. In addition to the usual outcomes used to measure success, such as hospital readmission rate and patient satisfaction, quality-of-life measures were used.
A descriptive, one group nonexperimental study was conducted to evaluate the effectiveness of a hospital to home program on postdischarge ED visits, hospital readmissions, quality of life, and patient satisfaction.
The study took place at a 961-bed, non-trauma-designated Magnet hospital located in the southeastern United States. The hospital's county has an estimated population of 45,236 residents aged 65 years and older (U.S. Census Bureau, 2010). The hospital's 2007 caseload for patients aged 65 years and older was 17,229, which represented 35% of the hospital's inpatient census. Of these, 53% were county residents. When examining hospital readmission rates for county residents, we found that 57% were aged 65 years and older.
Potential participants in the program had to meet two sets of inclusion criteria. First, patients had to be (1) 65 years or older, (2) a resident of the county in which the hospital is located, and (3) eligible for Medicare and/or Medicaid. In addition to these inclusion criteria, potential participants also were required to meet two or more of the following risk factors for readmission:
1. Two or more documented chronic conditions (e.g., chronic obstructive pulmonary disease, congestive heart failure, diabetes),
2. Physical disability or functional decline requiring assistance with activities of daily living,
3. History of falling in the past year requiring medical evaluation or treatment,
4. Polypharmacy (greater than eight medications at admission or discharge),
5. Cognitive decline or depression,
6. More than three physician visits in the past 6 months,
7. Three or more ED visits in the past 6 months,
8. Three or more hospitalizations in the past year,
9. Nutritional impairment (i.e., low prealbumin, unintended weight loss, and/or reduced food intake),
10. History of hospitalization for hip fracture in the past year, or
11. Limited social support (i.e., patient lives alone, has no immediate family, and/or is caregiver for someone else in home).
Two mechanisms were used to screen and identify patients who potentially met the inclusion criteria. An electronic alerting system based on patients' medical histories triggered a daily report of newly admitted patients. In addition, an online patient referral system based on the screening criteria allowed nurses, physicians, and case managers to request a consult to screen potential participants.
The study was approved by the hospital's institutional review board. Participants were fully informed regarding the nature of the intervention and the data required to evaluate the program. All participants signed an informed consent. Patients and their family members were notified that participation was voluntary and that they could stop the program at any time without negative reproach from program or hospital staff.
Because data were collected at varying times for the duration of the program, data collection tools contained patient identifiers (name and medical record number) to ensure data matching. All data collection tools were kept in locked file cabinets in locked offices at the hospital. Only researchers and research assistants associated with the study had access to the data files. Computer databases were password protected.
Participants were not financially compensated for participating. However, the program interventions were provided free of charge, which may have held a significant value for some.
Data were collected using several instruments. First, a researcher-designed screening tool was developed to collect initial demographic and clinical data to determine eligibility. Once participants consented to enroll in the program, a second researcher-designed tool, the enrolled patient form, was completed. This form was used to record more detailed patient demographic information, prior use of home health and social services as well as variables measuring Hospital to Home program usage (i.e., the number of navigator visits, hours of in-home assistance). If a patient was readmitted to the hospital while still in the program, a patient readmission form was completed to document the reason for readmission. When participants completed the program, they were asked to complete a patient satisfaction survey. This survey consisted of 16 items related to the program intervention. One question was a general satisfaction question. The other items asked about the reliability, accessibility, respectfulness, confidentiality, and overall satisfaction with the Hospital to Home navigator, in-home assistance staff, and other skilled home health personnel. These items were rated on a 5-point Likert-type scale with 5 (very satisfied) and 1 (very unsatisfied). Two open-ended questions asked about possible improvements to the program and most helpful aspects.
Since the SF-36 is a tool completed by the participants, it reflects the participants' perception of their health in a more personal, meaningful way. The health care quality of life was improved for both physical and mental health and all eight subscales.
In addition to these researcher-designed data collection tools, quality of life was measured using the 36-Item Short-Form Health Survey (SF-36). The SF-36 is a multipurpose health survey yielding a 5-scale profile of physical health, including a summary score of physical health, and a 5-scale profile of mental health, including a summary score of mental health. Because it is not disease-specific, it can be used with any population. The SF-36 has been widely used in health research to understand the burden of disease and the impact of various interventions. The 36 survey items require a Likert-type or dichotomous response to various physical and mental health questions. The SF-36 has been used with well more than 23,000 patients in various practice settings (Ware, 1993). Psychometric testing has shown strong internal consistency (0.82-0.93) (McHorney, Ware, Lu, & Sherbourne, 1994) and construct validity has been demonstrated in a variety of patient populations (Ware, 1993; Ware & Kosinski, 2001).
A Hospital to Home program was designed to meet the transition needs of frail elderly hospitalized patients after discharge. The foundational innovation of the program consisted of a frail elder navigator who identified eligible participants during their hospital admission, arranged support services to begin immediately after discharge, and scheduled a home visit within 72 hr of discharge. During the initial home visit, the navigator reviewed the discharge orders and medications, confirmed that services arranged prior to discharge were implemented, evaluated the home environment, helped the patient and family identify other needs, and provided community resource referrals to meet those needs. The SF-36 was administered at the initial visit. In addition to the social work navigator, the Hospital to Home program contracted with a state-licensed home care agency to provide immediate home care services at discharge. These services may have included transportation home from the hospital and to doctor appointments as well as light housekeeping, laundry, meal preparation, prescription pickup, and grocery shopping. These services were provided at no cost to the patient. The navigator followed the patient for at least 30 days and up to 4 months based on the navigator's assessment of patient needs. This 30- to 120-day time period for Hospital to Home services was determined through a community assessment and based on the average wait time for available older adult services in the county. When the patient was able to resume independent home living or was connected to necessary community supports, the patient was discharged from the program and completed end-of-program surveys. The navigator remained an information resource after discharge.
Between April 2009 and May 2011, 292 patients were enrolled in the study. The mean age was 80 (SD = 8) years and ranged from 63 to 100 years. Seventy-two percent were Caucasian, 28% were African American, and 1% were Hispanic/Latino. Less than one third (31%) were married. A little less than half (45%) met the 2008 national poverty guidelines.
Most of the participants (88%) suffered from chronic illnesses, including diabetes (38%), heart failure (32%), renal failure (27%), chronic obstructive pulmonary disease (24%), chronic pulmonary infections (22%), and Alzheimer's disease (16%). Most were physically disabled (63%) and 43% had symptoms of cognitive decline or depression. Falling was common with 29% experiencing a fall in the previous year and 5% of those falls resulted in a hip fracture. The majority (66%) was managing polypharmacy (eight or more medications) and 14% had nutritional impairment.
Most participants frequently accessed health providers in the previous year. About 50% had greater than three physician visits, 20% had three or more hospitalizations, and 20% had three or more ED visits. Other services utilized prior to admission included home health nursing (13%), Meals on Wheels (12%), and transportation services (10%).
Most participants identified social supports. Although 52% lived alone prior to hospital admission, 91% reported either spousal or family support. Only 7% depended entirely on community for support with no assistance from a spouse or family member and 1% reported no form of social support.
All of the participants were successfully discharged to home, with 48% going home alone. Approximately 28% of participants required an ED visit postdischarge and 22% required hospital readmission for any cause. The hospital readmission rate of county residents aged 65 years and older in 2007 was 57%. This represents a 61% reduction in hospital readmissions and a cost savings of approximately $628,202 per year to the hospital. This cost savings is based on the 2007 average direct cost of a 30-day readmission for this patient population. The total cost of our program is approximately $204,311 per year. These costs are well justified, given that our actualized savings were three times that amount.
To achieve these outcomes, participants spent an average of 63 days (SD = 44) in the program and received an average of 2.7 navigator visits, 3.5 navigator phone calls, and 16.0 hr of in-home assistance. For those receiving in-home assistance, an average of 10.0 visits were made and an average of 23.7 hr were used. Participants went an average of 12 days (SD = 10) between hospital discharge and their first primary care physician visit.
To assist with the transition to home, most participants required some type of home health services (94%), including skilled nursing (74%), physical therapy (73%), occupational therapy (37%), nursing assistance (27%), social work (8%), and speech (5%). In-home assistance was used by half of the participants, including housekeeping (54%), meals/shopping (40%), transportation (38%), and medication reminders (12%). Other services typically arranged by the navigator included durable medical equipment (43%), Meals on Wheels (30%), and referral to a faith-based community volunteer program that assists older adults in their home (22%).
Health care quality of life was measured with the SF-36, yielding two summary scales and eight subscales. Pre- and postprogram means are displayed in Table 1. Because the SF-36 is a tool completed by the participants, it reflects the participants' perception of their health in a more personal, meaningful way. The health care quality of life was improved for both physical and mental health and all eight subscales. Using a paired t test, the improvement was statistically significant for overall physical health (p < .001) and all four subscales: physical functioning (p < .001), role-physical (p < .001), bodily pain (p < .001), and general health (p = .004). The improvement was statistically significant for overall mental heath (p = .001) and all four subscales: vitality (p = .001), social functioning (p < .001), role-emotional (p = .002), and mental health (p < .001).
Patient/family surveys (n = 107) showed a high degree of overall satisfaction. Using a 5-point Likert scale, with 5 = very satisfied and 1 = very unsatisfied, the mean responses were as follows:
* overall satisfaction with the program = 4.85
* overall satisfaction with navigator = 4.92
* overall satisfaction with licensed home care agency = 4.83
* overall satisfaction with community services = 4.74
Almost all (99%) of respondents were satisfied with the overall Hospital to Home program, 100% of respondents were satisfied with the navigator, 100% of respondents were satisfied with the in-home assistance, and 97% were satisfied with the overall community services. Sample positive written comments included the following:
* "The services provided were a lifesaver. The people have been impressive. I am certain my surgery went well because of this program."
* "They cared a lot about me not going back to the hospital. That was awesome that people cared so much about me."
* "I would have a hard time with the transition had it not been for the program."
Negative written comments focused on glitches in the coordination of services ("Missed one week of housekeeping and no one called me") or expansion of services ("The program could have lasted longer").
As the American life expectancy and average age continues to increase, extending independent living at home is an important goal. This study targeted frail older adults most at risk for repeated hospitalizations but still living in their homes in an effort to maintain overall quality of life.
The results of this study show the importance of extending social support and health education into the home after discharge from the hospital. Without transportation to the doctor, grocery store, or pharmacy, many frail older adults who leave the hospital are unable to properly care for themselves when they return home. In addition, providing a navigator to assess the patient and the home environment often reveals risk factors unrecognized or not communicated during the hospital stay. The skills of a social worker are well suited to connect these patients to community supports for ongoing assistance and to work with patients and families to address unexpected needs. A social worker is also trained to address the denial of need expressed by some patients and families. Even with social worker involvement, regular in-home assistance is needed about 50% of the time to help with informal support with IADLs during the first few weeks after discharge. The communication between the in-home assistant and the navigator provides an opportunity to catch potential risks earlier, identify developing health problems, and prevent rehospitalizations.
After many years of trialing various transitional care programs to reduce readmissions, best practices are becoming generally accepted. For example, the California Quality Collaborative (2010) shares several elements of this program, including
* scheduling the initial navigator in-home visit before hospital discharge,
* teaching the patient in the home about warning signs that may lead to readmission,
* establishing a what-to-do plan for self-management,
* reconciling medication regimens and educating on appropriate use, and
* coordinating all follow-up services through navigator in-home visits and phone contacts.
As more program results are reported, the value of the navigator and in-home assistant is becoming widely recognized for improved physical and mental health outcomes. However, the worth of these services is virtually unrecognized by current reimbursement structures, and the expense of providing transition services is vastly assumed by acute care facilities. Efforts such as the new Medicare Community Based Care Transitions program sponsored by the Centers for Medicare and Medicaid Services are now accepting applications for demonstration projects. The outcomes of these projects will influence what services the Centers for Medicare and Medicaid Service reimburses in the future. Right now, hospitals can improve care for their patients after discharge by collaborating with community organizations to bridge gaps in care by initiating or strengthening transition services. Each hospital must assess the risk of lost revenue when 30-day readmissions will result in payment penalties versus the cost of providing transition programs to reduce readmissions. This model costs less to sustain than to cover the cost of readmissions if they were not reimbursed. The outcomes of our program lend needed support to justifying a redesigned reimbursement structure. The Hospital to Home program provides a low-cost, effective model to address many risk factors for readmission, including the lack of social support, low health literacy, access to follow-up health care and medications, and poor environmental conditions. This model empowers patients and families to ensure a successful transition to home.
This project was funded by The Duke Endowment for $316,795. The Duke Endowment underwrites innovative solutions that enhance the lives of individuals and the vitality of communities. Health care is a key funding focus.
Brown-Williams H. (2006, April). Dangerous transitions: Seniors and the hospital to home experience. In: Perspectives Health Research for Action (Vol. 1, No. 2, pp. 1-7). Berkley: University of California. [Context Link]
California Quality Collaborative. (2010). Developing programs to reduce hospital readmissions: Key design elements to consider from a physician group perspective. Retrieved June 10, 2011, from http://www.calquality.org/programs/costefficiency/resources/documents/CQC_Summar[Context Link]
Coleman E. A., Smith J. D., Frank J. C., Min S., Parry C., Cramer A. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. Journal of American Geriatric Society, 52, 1817-1825. [Context Link]
Jack B. W., Chetty V. K., Anthony D., Greenwald J. L., Sanchez G. M., Johnson A. E., Culpepper L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. [Context Link]
McHorney C., Ware J. E., Lu J. F., Sherbourne C. D. (1994). The MOS 36-Item Short-Form Health Survey (SF-36): Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care, 32(1), 40-66. [Context Link]
Naylor M. D., Brooten D., Campbell R., Jacobsen B. S., Mezey M. D., Pauly M. D., Swartz S. J. (2010). Comprehensive discharge planning and follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 281(7), 613-620. [Context Link]
Society of Hospital Medicine. (2011). Project BOOST: Better outcomes for older adults through safe transitions. Retrieved from http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDi[Context Link]
Medicare Payment Advisory Commission (MedPAC). (2007, June) Report to congress: Promoting greater efficiency in medicare (Chapter 5). Retrieved from http://www.medpac.gov/documents/Jun07_EntireReport.pdf.
U.S. Census Bureau. (2010). Profile of general population and housing characteristics: 2010. Retrieved June 13, 2011, from http://factfinder2.census.gov[Context Link]
Ware J. E. (1993). SF-36 Health Survey: Manual and interpretation guide. Boston, MA: The Health Institute, New England Medical Center. [Context Link]
Ware J. E., Kosinski M. (2001). Interpreting SF-36 summary health measures: A response. Quality of Life Research, 10(5), 405-413. [Context Link]
For more than 32 additional continuing education articles related to Case Management topics, go to http://NursingCenter.com/CE.
care transitions; discharge planning; frail older adults; hospital case management; over 65