Commentary

This study by Naylor et al adds to the growing body of research showing the positive effects of care delivered by APNs. The results show the human and financial value of individualised discharge planning based on a biopsychosocial model of care as well as attending to the transition between hospital and home, continuity of care, and interdisciplinary collaboration. The elderly patients in the study had one of several diagnoses, demonstrating that this intervention need not be disease specific.

Because the study was done in the US, the results cannot be generalised to other countries that may have different sociodemographic characteristics and reimbursement policies. The entire sample had high mental status examination scores and low depression scores, and therefore the effectiveness of similar interventions delivered to other high risk groups (eg, older adults with cognitive impairment or depression) is unknown. Also, generalisability may be limited because the sample consisted of primarily white, urban dwelling elderly people.The intervention did not affect functional status in the home, a finding that is concerning, but not surprising, and is consistent with the evolving geriatric literature on functional status in high risk elders after discharge from a specialised unit for acute elder care.^{1, 2} Despite lack of improvement in functional status, there were reductions in readmissions. The authors suggest that the APN intervention enhanced the capacity of high risk elderly patients to cope with their multiple medical problems and disabilities. The APNs had master's degrees and were gerontological nurse specialists who, in collaboration with the patient, physician, caregiver, and other team members, designed and implemented an individualised discharge plan within the bounds of the protocol. This study shows the value of continuous, individualised care during transitions from acute to post-acute care.