A recent study by Naylor and colleagues examined the effect of "transitional care" on older adults (mean age, 76) hospitalized with heart failure. In a randomized, controlled trial, patients in the intervention group (n = 118) received comprehensive care by specially trained advance practice nurses (APNs) that included individualized care plans across settings; at least eight home visits after discharge, with one within 24 hours and one weekly for the first month at home; and the availability of APNs by telephone seven days a week. The control group (n = 121) received the hospital's routine care, which included discharge planning. One year after initial hospitalization, patients in the intervention group showed significantly fewer hospital readmissions, a lower rate of death, fewer hospital days on readmission, and greater satisfaction with care than did patients in the control group. Also, costs in the intervention group were 37.6% lower.

These findings demonstrate the value of transitional care directed by highly skilled APNs who set up discharge plans; provide continuity in holistic care; and collaborate with physicians, patients, family, and community resources.

Naylor MD, et al. J Am Geriatr Soc 2004;52(5):675-84.