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

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Question In elderly people admitted to hospital, does a discharge planning and home follow up protocol implemented by advanced practice nurses (APNs) improve patient outcomes and reduce healthcare costs?


Randomised (concealed), single blind (outcome assessor) controlled trial with follow up at 24 weeks.


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 congestive heart failure, angina, myocardial infarction, respiratory tract infection, coronary artery bypass graft, cardiac valve replacement, major small and large bowel procedure, or lower extremity orthopaedic procedure. All patients had ≥1 risk factor for poor discharge outcomes (≥80 years of age; inadequate support system; multiple, chronic health problems; history …

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  • 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 +1 215 573 6659.

  • A modified version of this abstract appears in ACP Journal Club.