Susan Altfeld|Gayle Shier|Madeleine Rooney|Timothy J. Johnson|Robyn Golden|Kelly Karavolos|Elizabeth Avery|Vijay Nandi|Anthony J. Perry
Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial
University of Illinois at Chicago|Rush University Medical Center|Rush University Medical Center|Rush University|Rush University Medical Center|Rush University|Rush University|New York Academy of Medicine|Rush University Medical Center
identify needs encountered older adult patients hospital discharge assess impact telephone transitional care intervention stress health care utilization readmissions mortalityolder adult inpatients met criteria risk postdischarge complications randomized discharge electronic medical record intervention group participants received telephonebased enhanced discharge planning program intervention included biopsychosocial assessment individualized plan following program protocols address identified transitional care needs patients received followup call 30 days post discharge assess psychosocial needs patient caregiver stress physician followup833 intervention group participants experienced significant barriers care 733 group problems emerge discharge intervention patients likely usual care patients scheduled completed physician visits 30 days post discharge differences groups patient caregiver stress hospital readmissionatrisk older adults may benefit transitional care programs ensure delivery care ordered address unmet needs although patients received intervention likely communicate follow physicians absence impact readmission suggests intensive efforts may indicated affect outcome