The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.


The implementation of a transitional care model in which nurse practitioners (NPs) conducted telehealth visits within 3 days of hospital discharge was associated with reduced health care costs and increased rates of 14-day, in-office follow-up visits, according to research presented in a poster session at the 2021 American Academy of Nurse Practitioners National Conference (AANP 2021).

“APNs are uniquely positioned to bridge care gaps during the post-discharge period,” explained study author Victoria A. Blucher, DNP, CRNP, FNP-C, of the Baltimore Sleep and Wellness Center. “NPs are a cost-effective use of health care resources in today’s value-based health care climate.”

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Patients who are discharged from the hospital and do not present for follow-up have a 10 times higher likelihood of hospital readmission, Dr Blucher said. Less than half of patients’ follow-up with a primary care provider within 2 weeks of discharge, resulting in hospital readmissions that cost between $15 and $20 billion annually and affect 1 in 5 Medicare beneficiaries.

Other risk factors affecting hospital readmission include age (ie, 80 years or older with 2 or more chronic diseases), unclear discharge instructions, premature discharge, adverse drug events, socioeconomic factors, and history of falls, dementia, or polypharmacy.

NP-Led Strategy to Improve Follow-up Rates

Dr Blucher investigated whether a telemedicine visit with an NP within 3 days of hospital discharge followed by a 14-day, in-office visit could reduce 30-day readmission rates vs usual care.

The study cohort for this study included adults 18 years and older with an unplanned hospital admission who were recruited from a suburban primary care practice in Baltimore, Maryland. The intervention used a statewide database to identify discharged patients; contacted patients to schedule both telemedicine and office visits with an NP; targeted areas of medication reconciliation, including the need for home health services, care coordination, and symptom management; and provided early intervention to avoid rehospitalization and adverse events.

Overall, hospital readmission rates decreased from 22.4% to 18.2% over the course of the study period, while 14-day, in-office follow-up rates increased from 37% to 86%. Discharge to readmit time also increased from 6.7 to 10 days. The intervention was linked to a total health care cost savings of $40,700, representing a 37.3% reduction in cost over 3 months.

Findings Confirm Previous Research

Transitional care interventions have been well-studied and are documented to improve patient outcomes, reducing 30-day readmissions up to 1 year after initial hospitalization, Dr Blucher explained. Previous research on this topic has involved use of the Naylor Model in which an advanced practice registered nurse (APRN) identifies early signs of deterioration and expedited interventional care to prevent repeat hospitalizations. Research also suggests that bundled interventions typically are more effective than single interventions, with telephone follow-up alone not always linked to improved readmission rates.

Study limitations include small sample size and small group of readmissions in each group, high labor intensity for NPs and lack of Medicare reimbursement for telemedicine visits, lack of patients discharged from psychiatric or skilled nursing facilities, and inclusion of a homogenous population, which limits the generalizability of results.

Visit Clinical Advisor’s meetings section for complete coverage of AANP 2021. All conference sessions are available to registered attendees through August 31, 2021.


Blucher VA. Reducing 30-day hospital readmissions with a telemedicine intervention. Presented at: 2021 American Association of Nurse Practitioners National Conference (AANP 2021); June 15-20, 2021. Poster 17.