Reducing Preventable Hospitalizations With Two Models of Transitional Care.

Area of Science:

• Healthcare Management
• Nursing Practice
• Geriatric Care

Background:

• Transitional care models aim to reduce adverse events and healthcare utilization post-hospitalization.
• Existing research supports transitional care's effectiveness in reducing hospitalizations and costs.
• Limited comparative studies exist on the efficacy of different transitional care provider models.

Purpose of the Study:

• To compare the approaches and outcomes of two distinct transitional care programs.
• To evaluate the impact of a clinical nurse specialist (CNS) program versus a physician-led palliative care (PPC) program.
• To assess reductions in hospitalizations and emergency department (ED) visits for different patient populations.

Main Methods:

• Retrospective cohort study comparing 120-day pre- and post-intervention periods.
• Analysis of data from a CNS program (n=98) and a PPC program (n=41, post-exclusion).
• Utilized Wilcoxon matched-pairs signed-rank test for significance testing.

Main Results:

• CNS program: Significant reductions in ED visits (p < .005) and hospitalizations (p < .005).
• PPC program: Significant reduction in hospitalizations (p = .03), nonsignificant reduction in ED visits (p = .327).
• Both programs demonstrated value in decreasing rehospitalizations.

Conclusions:

• Both transitional care models effectively decrease rehospitalizations.
• The CNS intervention showed additional significant benefits in reducing ED visits.
• Further research, including randomized controlled trials, is needed to optimize transitional care workforce and cost-effectiveness.