Effectiveness of a nurse-managed follow-up program for rehabilitation patients after discharge

Former patients in a rehabilitation unit at a large Midwestern hospital continued to actively seek services provided by the inpatient nursing staff, primarily through telephone contact, long after their discharge. A proactive formal follow-up program managed by an advanced practice nurse in rehabilitation was proposed as a better means of providing continuing care for rehabilitation patients after discharge. To examine the efficacy of the nurse-managed follow-up program, a randomized clinical trial was conducted. One hundred patients were randomly assigned to either the intervention group or the control group. Comparisons were made between the two groups on several outcome measures at 4 months after discharge. Outcomes included Functional Independence Measure (FIM) instrument scores, complication rates, rehospitalizations, and anxiety levels. The organizational outcomes included number and types of calls to staff, as well as time spent by staff nurses and social workers. The results indicated significant differences between the intervention and control groups in terms of anxiety levels, the number of calls made to the unit, and the amount of time spent by staff nurses and social workers.