Objective: To examine whether use of a nurse case manager to coordinate postdischarge care would improve rates of follow-up, emergency department utilization, and unexpected readmission for general medicine patients.
Design: Prospective cohort trial.
Setting: Publicly supported, tertiary-care teaching hospital.
Patients: Four hundred seventy-eight patients admitted to the general medicine service.
Interventions: Use of a nurse case manager to provide discharge planning before hospital discharge and to arrange for postdischarge outpatient follow-up. Patients in the control group had discharge planning in the traditional ("usual care") manner.
Measurements and main results: The proportion of patients with scheduled outpatient appointments in the medical clinic and the proportion making clinic visits, emergency department visits, or with readmission to the hospital within 30 days following discharge. A significantly greater proportion of patients assigned to the nurse case manager intervention had appointments scheduled at the time of hospital discharge (63% vs 46%, p < .001), and made scheduled visits in the outpatient clinic (32% vs 23%, p < .03). Intervention group patients were especially more likely than control group patients to have definite follow-up appointments if they were discharged on weekends. Intervention and control group patients did not differ, however, in the rates of emergency department utilization (p = .52) or unexpected readmissions within 30 days of discharge (p = .11).
Conclusions: Use of a nurse case manager to coordinate outpatient follow-up prior to discharge improved the continuity of outpatient care for patients on a general medical service. The intervention had no effect on unexpected readmissions or emergency department utilization.