Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study.

Area of Science:

• Healthcare delivery research
• Nursing interventions
• Veteran health services

Background:

• Rural veterans often transfer to urban VA Medical Centers for care.
• The transition from hospital to home presents a vulnerable period for adverse events.
• Effective postdischarge support is crucial for this population.

Purpose of the Study:

• To evaluate the effectiveness of the rural Transitions Nurse Program (TNP).
• To assess TNP's impact on postdischarge follow-up and adverse events.
• To determine TNP's association with mortality reduction in veterans.

Main Methods:

• National hybrid-effectiveness-implementation study involving 3001 TNP participants and 6002 matched controls.
• Intervention included discharge readiness assessment, PCP communication, and postdischarge calls within 72 hours.
• Propensity-matched cohort design in 11 urban VA hospitals, controlling for clinical and demographic factors.

Main Results:

• TNP participants were more likely to have primary care provider (PCP) visits within 14 days (OR=2.24).
• TNP was associated with a significant reduction in 30-day mortality (HR=0.33).
• No significant association found between TNP and reduced 30-day emergency department visits or readmissions.

Conclusions:

• The Transitions Nurse Program (TNP) is associated with increased postdischarge follow-up and reduced mortality.
• Further research is needed to elucidate the mechanisms behind the observed mortality reduction.
• TNP shows promise for improving care transitions for rural veterans.