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advanced practice nurse, cardiac illness, discharge planning, hospitalized elders



  1. Naylor, Mary D. PhD, RN, FAAN
  2. McCauley, Kathleen M. PhD, RN, CS, FAAN


This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.