NPs improve care coordination for high-risk complex care patients post-discharge
Post-discharge care from hospital to community coordinated by an NP in high-risk complex care patients reduced hospital readmission rates.
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PHILADELPHIA – High-risk complex care patients who had a nurse practitioner (NP) manage their care in the 30 days following discharge had lower hospital readmission rates than those who did not, according to a pilot study presented at the American Association of Nurse Practitioners (AANP) 2017 National Conference.
The goal of the program, conducted by Ana Mola, PhD, RN, ANP-C, from the NYU Langone Medical Center, and colleagues from March 2015 to March 2016, was to target this patient population to better understand where to dedicate limited resources, improve their care transitions, and reduce the number of readmissions.
A total of 112 high-risk complex care patients were recruited for the study. NP-coordinated care resulted in a 31.03% readmission rate compared with 33.8% of matched controls before the start of the study. Baseline characteristics were similar between the readmitted and non-readmitted patients. Poor health literacy, high-risk medications or polypharmacy, and comorbidities were common in both groups.
The researchers noted that the majority of patients who were readmitted attended follow-up appointments and had social support. These patients, they added, were high-utilizers, hospital-dependent, had rapid disease progression, or were on a hospice trajectory.
“The role of the NP allows for real-time and real-world interventions to change the trajectory of the 30-day readmission rates of high-risk complex care patients,” the researchers wrote. “The real-time NP interventions focused on monitoring and reassessing clinical symptoms, diagnostic test results, and treatments, timely communication, hand-offs, or referrals to the next provider, engagement and education of the patient, family, or caregiver regarding self-care management for signs and symptoms, and an emergency care plan using teachback.”
- Mola A, Wynn C, Warltier K. Complex care NP: improving care of high-risk patients. Presented at the American Association of Nurse Practitioners 2017 National Conference; June 20-25, 2017; Philadelphia.