Care Coordination Relating to Elderly Annotated Bibliography

The results of this analysis highlight the need for hospitals to fine-tune their discharge process to reduce readmissions, and support the expenditure of additional resources for this purpose as a cost-effective intervention; as an example, author cites a hospital in Iowa that implemented a rigorous post-discharge planning process for patients with heart failure and 30-day readmission rates were reduced by 3-9% during the 3-month period following implementation.

Conclusion

The research showed that many elderly patients who suffer from congestive heart failure also suffer from a wide range of comorbid conditions, including diabetes and hypertension. These patients can be reasonably expected to require periodic or even frequent treatment in emergency departments and/or hospitalizations for these conditions, making the need for effective and seamless post-discharge planning especially important. In this regard, the research also showed that there are some valuable evidence-based practice guidelines available, though, that can help clinicians better coordinate post-discharge care, with interventions such as early assessment of discharge needs, improved patient and care-giver education, timely and complete communication between clinicians at the time of transfer, early post-acute follow up within 48-72 hours for high-risk patients with either a physician or nurse, early post-discharge nurse phone calls to confirm understanding of follow-up plan, and appropriate referral for home…