This annotated bibliography examines evidence-based practices for coordinating care for elderly patients with congestive heart failure (CHF), diabetes, and hypertension during the critical 30-day period following discharge from a hospital or emergency room. Drawing on more than a dozen peer-reviewed sources, the paper documents the high rates of CHF readmission (20–24% within 30 days), identifies proven interventions such as early discharge planning, interdisciplinary communication, medication management, and post-discharge follow-up calls, and highlights the role of comorbidities in complicating transitions of care. The paper concludes with a synthesis of key findings and practice recommendations for clinicians and healthcare administrators.
A growing body of evidence supports the need for careful care coordination for elderly patients who suffer from congestive heart failure, diabetes, and/or hypertension for at least 30 days following their discharge from a hospital or emergency room. To determine the current best practices and guidance in this area, a summary of the relevant literature is provided below in an annotated bibliographic format, followed by a synthesis of the research and important findings in the conclusion.
Bisognano, M. & Boutwell, A. (2009). Improving transitions to reduce readmissions. Frontiers of Health Services Management, 25(3), 3–5.
The authors report that a growing body of research confirms the high rates of readmissions for patients with conditions such as heart failure, chronic obstructive pulmonary disease, and depression. Among the populations studied, congestive heart failure (CHF) 30-day readmission rates were shown to be especially high, ranging between 20–24%. The authors cite the following as proven effective interventions: (a) early assessment of discharge needs; (b) enhanced patient and caregiver education, specifically focused on understanding the management of the patient's condition; (c) timely and complete communication between clinicians at the time of transfer; (d) early post-acute follow-up within 48–72 hours for high-risk patients with either a physician or nurse; (e) early post-discharge nurse phone calls to confirm understanding of the follow-up plan; (f) appropriate referral for home care services when needed; (g) appropriate advanced care planning; (h) remote monitoring; (i) improved transfer processes between facilities; and (j) effective medication management.
Boughton, B. & Halliday, L. (2009). Home alone: Patient and carer uncertainty surrounding discharge with continuing clinical care needs. Contemporary Nurse: A Journal for the Australian Nursing Profession, 33(1), 30–32.
The authors report that timely discharge planning is an important ingredient in patient care and is of particular importance to short-stay or early-discharge patients. Discharge planning is widely regarded as the primary mechanism by which the post-hospitalization discharge needs of the elderly are addressed.
Byrnes, J. & Fifer, J. (2010). Recommendations for responding to changes in reimbursement policy. Frontiers of Health Services Management, 27(1), 3–5.
The authors report that there is a fundamental need for after-discharge hospital assessment at admission to include key family members and community support organizations, with the goal of beginning discharge planning on arrival and having a completed plan by discharge. The authors add that electronic medical record screens have also been improved to facilitate communication between all caregivers involved in this process, including primary care physicians, medication planning — which is especially important — and/or coordination of transition to another facility.
Callaly, T., Hyland, M., Trauer, T., Dodd, S. & Berk, M. (2010). Readmission to an acute psychiatric unit within 28 days of discharge: Identifying those at risk. Australian Health Review, 34(3), 282–290.
The authors note that elderly patients with a history of hospital readmissions should be targeted for specialized attention during the immediate post-discharge period, as many previous readmissions have been shown to be preventable with more effective discharge planning.
Chugh, A., Williams, M.V., Grigsby, J. & Coleman, E.A. (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management, 25(3), 11–13.
The authors provide a series of case studies of elderly patients hospitalized for various heart conditions. They emphasize the need to ensure that elderly patients are able to thoroughly understand the directions given to them for the post-discharge period — a process that can be constrained by hearing loss or cultural and language barriers. The authors recommend the use of human or computerized assistants to conduct follow-up telephone calls to patients during the early post-discharge period.
In a related discussion, the authors also report that a number of constraints to providing effective discharge instructions following hospitalization are attributable to the healthcare system or the individual practitioner. Numerous studies have shown that clinicians' use of medical terminology, together with patients' limited ability to understand complicated health language, results in inadequate and even confusing communication between providers and patients. Based on primary data collected for the study, the authors conclude that repetition of instructions, post-discharge follow-up and reminders, and the use of a computerized assistant that calls patients at home after discharge are essential elements of post-discharge planning. Additional recommendations include simplifying written materials by using plain language, larger fonts, diagrams and pictures, information tailored to the patient's learning strengths, and careful attention to how information is organized. The authors acknowledge, however, that not all post-discharge information can be simplified in this fashion.
Scott, I.A. (2010). Preventing the rebound: Improving care transition in hospital discharge processes. Australian Health Review, 34(4), 445–447.
The author presents the results of a review of studies examining patient and carer perceptions of the hospital discharge process in order to identify the most commonly reported complaints. These included: (a) poor communication and consultation by staff — 10% of patients were not told the purpose of their medications, 44% were not told of sentinel side effects, and 41% were not told of danger signs suggesting disease relapse; (b) inadequate notice of discharge timing and inadequate assessment of home circumstances; (c) lack of involvement in discharge arrangements; and (d) uncertainty regarding the coordination of post-discharge services. The results highlight the need for hospitals to refine their discharge processes to reduce readmissions and support the expenditure of additional resources for this purpose as a cost-effective intervention. As an example, the author cites a hospital in Iowa that implemented a rigorous post-discharge planning process for patients with heart failure and achieved a reduction in 30-day readmission rates of 3–9% during the three-month period following implementation.
Clairborne, N. & Vandenburgh, H. (2001). Social workers' role in disease management. Health and Social Work, 26(4), 217–219.
"Case management models and interdisciplinary coordination"
"System reforms, VA records, and hospital-level outcomes"
The research showed that many elderly patients who suffer from congestive heart failure also suffer from a wide range of comorbid conditions, including diabetes and hypertension. These patients can be reasonably expected to require periodic or even frequent treatment in emergency departments and/or hospitalizations for these conditions, making the need for effective and seamless post-discharge planning especially important.
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