Our current health care system tends to focus on hospital care, with less emphasis on recovery and rehabilitation in the home. The result is often readmission to the hospital. One study found that seniors hospitalized with heart failure often have multiple medical conditions, and they have the highest hospital readmission rate of all adult patient groups. This indicates a serious breakdown during the transition from the hospital to home care.
Nurse scientist Dr. Mary Naylor, a professor at the University of Pennsylvania, was part of an interdisciplinary research team addressing this breakdown. They used a model of care in which advanced practice nurses worked with the seniors to develop discharge plans and coordinate care in the transition from hospital to home. In the year after their discharge, those who received this transitional care had fewer hospital readmissions, hospital days, and deaths, along with a higher quality of life and greater satisfaction with their care, than those who continued in standard care. In addition, their total health care costs were lower by almost $5,000 per patient. A major national health insurer is further evaluating the success of transitional care.