Talking With a Nurse Reduces Hospital Readmissions

Weekly telephone contact with a nurse can substantially reduce hospital readmission rates for high-risk patients, according to a new study.

Developed by researchers at the University of Wisconsin (Madison, USA), the Coordinated-Transitional Care (C-TraC) protocol was designed to improve care coordination and outcomes among US veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital (Madison, WI, USA). Under the program, 605 patients worked with nurse case managers on care and health issues, including medication reconciliation and before and after hospital discharge, with all contacts made by phone once the patient was at home.

Patients in C-TraC protocol were phoned by a nurse case manager 48-72 hours after discharge. The nurse met with each patient before discharge to arrange for the phone calls and with each patient’s hospital providers to help ensure that the patient’s transition home was as smooth as possible. During the phone call, the nurse engaged the patient in an open-ended discussion, talking about medications, follow-up, and the appropriate response to any signs and symptoms that the patient’s medical condition could be worsening. The results showed that patients who received the C-TraC protocol had one-third fewer rehospitalizations than the control group, producing an estimated savings of USD 1,225 per patient. The study was published in the December 2012 issue of Health Affairs.

“Many patients, within two days of discharge, were not taking their medications properly,” said lead author assistant professor Amy Kind, MD, of the School of Medicine and Public Health. “They may not have understood what they should have been doing, or became confused about their medications when they arrived home. Our nurse can help them work through those issues and make sure they are doing things as they should.”

“This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act,” added Dr Kind. “In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.”

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