Current issues of ACP Journal Club are published in Annals of Internal Medicine


Discharge planning and home follow-up by advanced practice nurses reduced readmissions of elderly patients

ACP J Club. 1999 Sept-Oct;131:32. doi:10.7326/ACPJC-1999-131-2-032

Source Citation

Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. A randomized clinical trial. JAMA. 1999 Feb 17;281:613-20.



What is the effectiveness of a discharge-planning and home follow-up protocol implemented by advanced practice nurses (APNs) for hospitalized patients?


Randomized controlled trial with 24-week follow-up.


2 university-affiliated hospitals in Philadelphia, Pennsylvania, USA.


363 patients ≥ 65 years of age (mean age 75 y, 50% men, 55% white) who were admitted from home with 1 of the following: congestive heart failure, angina, myocardial infarction, respiratory tract infection, coronary artery bypass graft, cardiac valve replacement, major bowel procedure, or lower-extremity orthopedic procedures. All patients had ≥ 1 risk factors for poor discharge outcomes (age ≥ 80 years, inadequate support system, multiple chronic health problems, history of depression, moderate to severe functional impairment, multiple hospitalizations during previous 6 mo, hospitalization in past 30 d, fair or poor self-rated health, or history of nonadherence, 72% completed the study.


177 patients were allocated to the APN intervention, which extended from admission to 4 weeks after discharge. 5 gerontologic APNs implemented a standardized discharge planning and home follow-up protocol that included APN visits during hospitalization, home visits, telephone availability, and weekly telephone contact. 186 patients allocated to the control group received routine discharge planning, including standard home care if referred.

Main outcome measures

Outcomes included readmissions (cumulative hospital days, mean length of stay), time to first readmission, and estimated cost of health services after discharge (based on standardized Medicare reimbursements).

Main results

Readmission results were based on all allocated patients. At 24 weeks, patients in the APN group were less likely to be readmitted (Table) and had a longer time to first readmission (P < 0.001). They had fewer days in the hospital (270 vs 760 d, P < 0.001), shorter stays (mean length of stay 7.5 vs 11.0 d, P < 0.001), and lower affiliated costs (U.S. $3630 vs $6661/patient, P < 0.001).


Among elderly inpatients at risk for hospital readmission, discharge planning and home follow-up by an advanced practice gerontologic nurse reduced hospital readmissions and increased length of time from discharge to readmission.

Source of funding: National Institute for Nursing Research.

For correspondence: Dr. M.D. Naylor, University of Pennsylvania School of Nursing, 420 Guardian Drive, Philadelphia, PA 19104, USA. FAX 215-573-6659.

Table. Advanced practice nurse (APN) discharge and follow-up vs usual care at 24 weeks*

Outcome APN program Control RRR (95% CI) NT (CI)
≥ 1 readmission 20.3% 37.1% 45.2% (22.9 to 61.3) 6 (4 to 15)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


It is standard practice for hospitalized older patients to be discharged home or to a skilled nursing facility while the acute illness or injury is still under active treatment. The demonstration by Naylor and colleagues of a reduction in the 24-week readmission rate of hospitalized elderly patients who were followed by APNs highlights critical problem areas affecting the successful management of older transitional-care patients. The medical care between the hospital, nursing home, and primary care settings frequently fails because of ineffective communication among providers to ensure that comorbid conditions and functional needs are properly addressed. The often-intricate care set up by discharge planners for homebound elderly patients may fall through without adequate follow-up after discharge (1). Noncompliance with medication, which occurs in nearly half of elderly patients after discharge (2), may be missed without pill counts or direct assessment of the patient's understanding and tolerance of the medications. Subacute care, whether in a skilled nursing facility or through a home help organization, tends to be goal directed and dictated by physicians and lacks the freedom to address broader health care needs and concerns of patients and caregivers.

Naylor and colleagues speculate that reasons for the success of their intervention included the APN's more timely communication and effective collaboration with the physician, as well as improvements in the patient's medical self-management. Their results imply that the study's primary care physicians, in the absence of case managers, were unable to provide the degree of oversight required to keep fragile elderly persons from being readmitted. This underscores the need for greater physician accessibility and better physician-patient communication. Setting aside specific hours for patients to call in and using proactive telephone follow-up in selected cases may help clinicians improve the quality of their transitional care for hospitalized elderly persons (3).

Calvin H. Hirsch, MD
University of California at DavisSacramento, California, USA


1. Simon EP, Showers N, Blumenfield S, Holden G, Wu X. Delivery of home care services after discharge: what really happens. Health Soc Work. 1995;20:5-14.

2. Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc. 1998;46:174-80.

3. Studdiford JS III, Panitch KN, Snyderman DA, Pharr ME. The telephone in primary care. Prim Care. 1996;23:83-102.