The Effectiveness of a Care Transitions and Rapid Response Nurse Intervention at Reducing Readmissions and Emergency Department Use for High Risk Patients

The transition from hospital to home is a vulnerable period for the elderly patient with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the postdischarge period. This article presents the results of a randomized control trial evaluating the effectiveness of an intervention involving a care transitions nurse and a rapid response nurse at lengthening the time to first readmission, emergency department use and total hospital bed days during the 30 days, 60 days and 90 days post-discharge periods for patients at high risk of readmission. The intervening impact of social isolation and patient frailty was also evaluated. No statistically significant differences were found between the intervention and control groups on the time to first readmission or in the post-discharge emergency department or inpatient bed use. Social isolation and frailty were not shown to significantly influence these outcomes.