The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.
Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition.
The growing number of patients with congestive heart failure has increased both the pressure on hospital resources and the need for community management of the condition. Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines' recommendations for coordination and education. Positive outcomes have been reported from trials evaluating multiple interventions, enhanced hospital discharge, and follow-up through the addition of a case management role. The question remains if similar gains could be achieved working with usual hospital and community nurses.
                A 12-week, prospective, randomized controlled trial was conducted of the effect of transitional care on health-related quality of life (disease-specific and generic measures), rates of readmission, and emergency room use. The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge.
                At 6 weeks after hospital discharge, the overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was better among the Transitional Care patients (27.2 +/- 19.1 SD) than among the Usual Care patients (37.5 +/- 20.3 SD; P = 0.002). Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ's Physical Dimension and Emotional Dimension subscales. Differences in generic quality life, as assessed by the SF-36 Physical component, Mental Component, and General Health subscales, were not significantly different between the Transition and Usual Care groups. At 12 weeks postdischarge, 31% of the Usual Care patients had been readmitted compared with 23% of the Transitional Care patients (P = 0.26), and 46% of the Usual Care group visited the emergency department compared with 29% in the Transitional Care group (chi2 = 4.86, df 1, P = 0.03).
                There were significant improvements in health-related quality of life (HRQL) associated with Transitional Care and less use of emergency rooms.