Article ID | Journal | Published Year | Pages | File Type |
---|---|---|---|---|
2663368 | The Journal for Nurse Practitioners | 2015 | 5 Pages |
•Transitional care is a growing area of health care.•A transitional care program was developed.•Telephone calls and home visits for 30 days after discharge.•Several themes identified with hospital readmissions.•Rapid follow-up is essential.
Geriatric patients are a highly vulnerable population and are at increased risk for hospital admission and readmission. A university hospital implemented the Geriatric Transitional Care program, aimed at improving quality of care and reducing 30-day hospital readmission rates. Enrolled patients received telephone calls, and, if there was high risk for readmission, home visits from a nurse practitioner. Twenty-six (6.6%) inpatient-to-inpatient readmissions occurred, which was a 48% reduction from the hospital-wide readmission rate. Causes of readmissions fell into 6 categories. Transitional care can reduce frequency, serve as a point of contact, and monitor discharge follow-up.