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J Am Geriatr Soc. 2009 Sep;57(9):1540-6. doi: 10.1111/j.1532-5415.2009.02430.x. Epub 2009 Aug 18.

A quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes.

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  • 1Department of Medicine, Bayview Medical Center, School of Medicine, Johns Hopkins University, Baltimore, Maryland 21224, USA.



To study the feasibility and effectiveness of a discharge planning intervention.


Quasi-experimental pre-post study design.


General medicine wards at three hospitals: an academic medical center, a community teaching hospital, and a community-based nonteaching hospital.


All patients aged 65 and older admitted to the hospitalist services.


The intervention toolkit had five core elements: admission form with geriatric cues, facsimile to the primary care provider, interdisciplinary worksheet to identify barriers to discharge, pharmacist-physician collaborative medication reconciliation, and predischarge planning appointments.


Thirty-day readmission and return to emergency department rates and patient satisfaction with discharge. Odds ratios were determined, and site effects were examined accordig to interaction terms and Breslow Day statistics.


Two hundred thirty-seven patients were followed during the preintervention period, and 185 were exposed to the intervention. Patients characteristics were similar across the two time periods. The proportion of patients with high-quality transitions home, measured according to Coleman's Care Transition Measures, increased from 68% to 89% (odds ratio (OR)=3.49, 95% confidence interval (CI)=2.06-5.92). Return to the emergency department within 3 days of discharge was lower in the intervention period (10% vs 3%, OR=0.25, 95% CI=0.10-0.62). At 30 days, there was a lower rate of readmission (22% vs 14%, OR=0.59, 95% CI=0.34-0.97) and fewer visits to the emergency department (21% vs 14%, OR=0.61, 95% CI=0.36-1.03) (P=.06).


When hospitalized elderly patients are treated with consideration of their specific needs, healthcare outcomes can be improved.

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