Maureen Salamon

June 27, 2017

PHILADELPHIA — When older patients are visited in the hospital by a nurse practitioner, rates of readmission in the 30 days after discharge can be reduced dramatically in this vulnerable population, according to a pilot study.

"It's no longer the case that the primary care provider takes care of the patient in the hospital," said investigator Katie Wingate, DNP, an adult-gerontological primary care nurse practitioner at Kernersville Primary Care in North Carolina.

"It's strangers who do that now, and that's terrifying," she told Medscape Medical News. "We're sort of providing a familiar face for the patient. It's pretty simple."

And hospital readmissions are "a big, expensive problem" in the United States, she pointed out.

The risk for readmission is greatest when follow-up is insufficient during the transition period. In fact, in her literature review, Dr Wingate found that patients whose hospitalizations are not followed up by their primary care provider are "10 times more likely to have a readmission."

National readmission rates for Medicare patients hover just under 18%, despite dropping by an average of 8% nationally from 2010 to 2015, the Centers for Medicare & Medicaid Services (CMS) announced last September, as reported by Medscape Medical News. After implementation of the Hospital Readmissions Reduction Program in October 2012, CMS payments were cut to hospitals with excessive 30-day readmission rates for specified conditions.

Curbing Readmissions
In an effort to further reduce rates, Dr Wingate developed an approach designed to close the gap between acute and primary care when elderly patients transition from the hospital back into the community.

She tracked the 30-day outcomes of 10 elderly patients discharged from a local hospital who were part of a three-step care transition intervention, which included a nurse practitioner visit during hospitalization.

"A lot of times, there's a discharge coordinator, but that person isn't typically the patient's primary care provider," she said. "That's the most unique thing" about this intervention.

She presented the results here at the American Association of Nurse Practitioners 2017 National Conference.

During the hospital visit, the nurse practitioner reviewed the patient's chart, answered any questions the patient had about the care plan, and explained what the follow-up would be after discharge. Within 2 days of discharge, the nurse practitioner phoned the patient and scheduled a follow-up appointment to take place 7 to 14 days after discharge.

All study participants were diagnosed with heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, pneumonia, diabetes, or hypertension. Average age of the cohort was 84 years, nearly seven in 10 patients were women, and all were white.

None of the study participants were readmitted to a hospital within 30 days of discharge, Dr Wingate reported. The research initially included 16 patients older than 65 years, but two died during the 30-day postdischarge period, three chose not to continue study participation, and one was discharged to a hospice setting.

The biggest obstacle to the intervention was the time required to visit hospitalized patients, which took away from the practice. But it paid dividends later, because postdischarge office visits proceeded much more smoothly, Dr Wingate reported.

A Familiar Face
"The office was a lot easier because I was familiar with what happened in the hospital," she said. "It was very fluid and efficient, and I actually got to talk to the patient and not search through charts to try to figure out what had happened."

"For me, that was the biggest success, because it puts clinical significance to the whole thing," Dr Wingate added. "It might improve the flow of the whole practice, which always benefits patients."

Before conducting this research, Dr Wingate's small, independently owned practice wasn't consistently notified when any of its elderly patients was admitted to the local 50-bed hospital.

It might improve the flow of the whole practice, which always benefits patients.

This meant "we couldn't really provide good care for them when they got out," she explained. This scenario has since changed, however, with the introduction of a remote hospital access system.

Some nurse practitioners in the audience reported that hospitalized patients at their facilities are closely followed after discharge in an attempt to reduce readmissions.

"Number one, people do better in their own home than in the hospital, so helping them stay out of the hospital is key," said Belinda Crider, ACNP, from Henry Ford Hospital in Detroit. "Number two, readmissions are very expensive for the hospital," she told Medscape Medical News.

At Henry Ford, for example, patients with congestive heart failure are phoned by a nurse navigator when they arrive home from the hospital and again the following day, and a nurse visits each patient on the third day. This intervention that has cut short-term readmissions in this patient group by more than 50%, Crider reported.

This type of research is important because it demonstrates that "everyone is responsible for keeping patients out of the hospital," including physicians and nurses, said Emily Wreford, MSCNP, from the Cleveland Clinic.

"I hope nurse practitioners can see how they can incorporate this intervention into their practice and how this can be feasible and practical and help prevent readmissions," said Dr Wingate, who noted that further research is needed with a larger sample and a longer follow-up period.

Dr Wingate, Ms Crider, and Ms Wreford have disclosed no relevant financial relationships.

American Association of Nurse Practitioners (AANP) 2017 National Conference. Presented June 23, 2017.

Follow Medscape Nurses on Twitter @MedscapeNurses and Maureen Salamon @maureensalamon


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