Transitional care programs lower hospital readmission rates, two studies show

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Seniors who leave hospitals and are placed in transitional care programs are far less likely to be return, two new studies assert. The authors cite both health and cost benefits of these post-acute options.

For one study, investigators followed 257 older patients who worked with a coach following a hospital discharge. The coach visited patients in the hospital, in their home, and completed two follow-up phone calls. Patients who worked with a coach after their discharge had a hospital readmission rate of 12.8%. The rate for patients not working with a coach topped 20%. Full findings appear in the July 25 issue of the Archives of Internal Medicine.

In a separate study, investigators from Baylor Health Care Systems followed 56 heart failure patients over the age of 65 who were discharged from the hospital into their home. Advanced practice nurses visited study participants one time prior to discharge from the hospital, and eight times later. A readmission rate for the group receiving house calls was 48% lower than for patients who did not receive this intervention, investigators found.

"Preliminary results suggest that transitional care programs reduce 30 day readmission rates for patients with heart failure," the authors wrote. "This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals."