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Posted: April 14th, 2020

Reducing Readmissions Among High-Risk Geriatric Patients

Reducing Readmissions Among High-Risk Geriatric Patients
Hospital readmissions are a major challenge for the health care system, especially for older adults who often have multiple chronic conditions and complex care needs. According to a recent study, about 20% of Medicare beneficiaries are readmitted within 30 days of discharge, and 34% within 90 days. These readmissions are costly, burdensome, and potentially avoidable with better care coordination and transitional care.

Transitional care is defined as “a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” . It includes interventions such as patient education, medication reconciliation, discharge planning, follow-up appointments, home visits, and telehealth.

High-risk geriatric patients are those who have multiple comorbidities, functional limitations, cognitive impairment, polypharmacy, or social isolation. They are more likely to experience adverse events, complications, and poor outcomes after hospitalization. Therefore, they may benefit from tailored transitional care programs that address their specific needs and preferences.

Several studies have shown that transitional care interventions can reduce readmissions and improve quality of life for high-risk geriatric patients. For example:

– A randomized controlled trial of the Care Transitions Intervention (CTI), a low-cost coaching model that empowers patients and caregivers to manage their health conditions and navigate the health system, found that it reduced 30-day readmission rates by 38% and 90-day readmission rates by 30% compared to usual care .
– A systematic review and meta-analysis of 47 studies of transitional care interventions for older adults with heart failure, a common cause of readmission, found that they reduced all-cause readmissions by 18% and heart failure-related readmissions by 25% at 12 months .
– A randomized controlled trial of the Transitional Care Model (TCM), a nurse-led intervention that provides comprehensive in-hospital planning and home follow-up for chronically ill older adults, found that it reduced total readmissions by 36% and lowered health care costs by 39% over 12 months .

These examples illustrate the potential benefits of transitional care for high-risk geriatric patients. However, there is no one-size-fits-all approach to transitional care. Different patient populations may require different types of interventions, depending on their risk factors, preferences, and resources. Therefore, health care providers should assess the needs of each patient and tailor the transitional care plan accordingly. Some of the factors to consider include:

– The patient’s level of health literacy, self-efficacy, and motivation to engage in self-care.
– The patient’s social support network, including family members, friends, and community resources.
– The patient’s access to transportation, communication, and technology.
– The patient’s goals of care and preferences for end-of-life care.
– The patient’s comorbidities, medications, and potential drug interactions.
– The patient’s functional status, cognitive status, and risk of falls.

By addressing these factors, health care providers can design and implement transitional care interventions that are effective, patient-centered, and culturally sensitive. Moreover, they can collaborate with other members of the health care team, such as pharmacists, social workers, case managers, and home health aides, to ensure continuity and coordination of care across settings.

In conclusion, reducing readmissions among high-risk geriatric patients is a vital goal for improving health outcomes and reducing health care costs. Transitional care interventions can help achieve this goal by providing comprehensive and individualized support for older adults during their transition from hospital to home. By applying the best evidence and practices of transitional care, health care providers can enhance the quality and safety of care for this vulnerable population.


: Jencks SF et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
: Naylor MD et al. Transitional care: moving patients from one care setting to another. Am J Nurs. 2004;104(9):58-63.
: Coleman EA et al. The Care Transitions Intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828.
: Feltner C et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774-784.
: Naylor MD et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620.


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