The effectiveness of a care transitions and rapid response nurse intervention at reducing readmissions and emergency department use for high risk patients: a mixed methods study

The transition from hospital to home is a vulnerable period for the elderly patient with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Achieving seamless transitions between care settings is viewed as crucial to high-quality care for frail older persons. Care transitions interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. This mixed methods study evaluates the effectiveness of a care transitions and rapid response nurse intervention at lengthening the time to first readmission and reducing total readmissions, emergency department use and total hospital bed days during the 30-day, 60-day and 90-day post-discharge periods for patients at high risk of readmission. The intervening impact of social isolation and patient frailty is evaluated. A randomized control trial was undertaken to evaluate the effectiveness of the intervention. Analysis was completed using the intention-to-treat principle. The primary end-point - the time to first readmission - was analyzed using the Kaplan-Meier survival analysis. The Fisher’s exact test compared differences in the post-discharge period, on the number of readmissions and emergency department visits and the Mann-Whitney-U test for hospital bed-days used. The intervening impacts of frailty and social isolation were evaluated using the independent t-test, Pearson correlation and two-way analysis of variance. Patient satisfaction with transition was evaluated using the Care Transitions Measure. Factors associated with inpatient and emergency department use were analyzed using a linear mixed model approach. No statistically significant differences were found between the intervention and control groups on the time to first readmission or in the post-discharge emergency department or inpatient bed use. Social isolation and frailty were not shown to significantly influence these outcomes but frailty was shown to be significantly associated with death. Men living alone were found to be more socially isolated. Linear mixed model analysis demonstrated that gender and previous emergency department and inpatient bed use to be significant predictors of future emergency department, readmission and inpatient bed use. No differences in patient satisfaction with the transitions were found between the intervention and control groups. A qualitative analysis was undertaken using focus groups and individual interviews, involving providers, to identify the factors that facilitated or were barriers to the implementation of this care transitions intervention. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included: issues of role clarity, role awareness and acceptance of the positions within the respective organizations, the adequacy and reinforcement of coordinating mechanisms, and the effectiveness of the information exchange protocols. The combination of these factors limited the ability of the professionals to work effectively together to achieve the patient outcomes desired. Several improvement opportunities were identified. The activities of the individual professionals delivering care were patient focused.Doctor of Philosophy (PhD) in Interdisciplinary PhD in Rural and Northern Healt