The Effect of Community Nurse-Led Transitional Care Program to enhance Patient and Health Service Utilization Outcomes for the Older Adults with High Risk Hospital Readmissions: A Randomized Controlled Trial

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Abstract Summary
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Authors (including presenting author) :
Wong YF (1), Yu SFD (2), Wong SP(1), Tsing WL(1), Chick Y L(1), Chung SC (1), Leung SS(1), Li KY(1), Heung LW(1), Chan WMM(1)
Affiliation :
(1) Community Nursing Service, Princess Margaret Hospital, (2) The Nethersole School of Nursing, The Chinese University of Hong Kong.
Introduction :
Elderly patients with chronic illnesses are discharged from hospital early in response to the overstretched hospital services. However, a substantial amount of evidence had identified the shortcomings of under-prepared hospital discharge for elderly patients and would easier lead to an increased risk hospital readmission.
Objectives :
The aim of the study is to develop community nurse-led transitional care program and examine its effect to enhance post-discharge outcomes of elderly patients with chronic illnesses who are at high risk readmission.
Methodology :
The transitional care model (TCM), which was developed by Naylor et al. (2010),was used as framework to guide the entire care of elderly patients from hospital to home, including chronic disease management. A 8–week single blind randomized controlled trial study was conducted. The subjects were recruited from medical wards. They were randomly assigned into either intervention or control groups. The primary outcomes of the hospital service utilization in terms of the number of hospital readmissions, number of AED visits and length of hospital stays were evaluated. The secondary outcomes were measured including psychological status by using Hospital Anxiety and Depression Scale (HADS), quality of life by using the Chinese version of the EuroQoL-5D (EQ-5D) questionnaire; self-efficacy by using Chinese version of the short-form chronic disease self-efficacy scales (CDSES-SF).
Result & Outcome :
A total of 106 subjects were recruited in the study with attrition rate of 7.5%. The mean age was 80 years and 67% were male. The results indicated that those who received transitional care had significantly fewer events in terms of hospital readmission and AED utilization by the evaluative endpoint at 4 weeks ( p=0.045). By the evaluative point at the 8 weeks and 12 weeks after hospital discharge, it was found that those who received transitional care had significantly lower rate of AED utilization (p=0.026) and (p=0.021) respectively. The generalized estimating equations (GEE) analysis affirmed that the intervention group had significantly greater improvement in depression status across the evaluative endpoints at 8th week (p=0.035) and also self-reported health –related quality of life in EQ-5D visual analogue scale scores (p=0.021). The study affirms that community nurse-led care interventions are feasible and effective in applying into the local health care context to improve post-discharge outcomes of the elderly patients.

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