A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly

Abstract

Purpose: This article reviews 15 clinical trials of nurse-assisted case management intended to improve posthospital transitions of elderly patients to other settings.

Primary practice setting(s): Hospitals.

Methodology and sample: The trials were selected after a systematic search of the PubMed database for the period 1996 to 2006.

Results: Eight of the 15 interventions showed reduced hospital readmission rates and/or fewer hospital days. These findings were observed across patients with "all cause" and heart failure, a variety of hospital types, and variations in the intervention. Reductions in the use of emergency departments were observed in 3 of the 11 studies investigating this. Lower expenditures were reported by all 6 studies reporting such comparisons.

Implications for cm practice: Home visits/continuous contact with patients, early postdischarge and frequent contacts, patient education, and the use of specialized nurses who could offer appropriate training and coaching were often credited as program strengths.