Enhancing the Transition from Hospital to Home for the Older Adult

1Johns Hopkins Bayview Medical Center, Baltimore, MD
2Geisinger Medical System, Danville, PA
3North East Medical Center, Concord, NC
4Johns Hopkins Bayview Medical Center, Baltimore, MD
5Johns Hopkins Hospital, Baltimore, MD
6Johns Hopkins Bayview Medical Center, Baltimore, MD

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 76


When elderly patients are discharged home following an acute hospitalization, they are at high risk of having an unsuccessful transition with untoward health care outcomes. Our team has developed an interdisciplinary, comprehensive intervention to try to make this transfer higher quality and less dangerous.


The goals of the study were: (1) to assess elements reflecting the existing risk associated with the transition of elderly patients from hospital to home; (2) to demonstrate that this discharge tool kit results in improved health care outcomes including (a) medication reconciliation resulting in reduced medication errors on returning home and (b) reduction in readmissions and emergency department visits within 30 days; and (3) to increase patient satisfaction with the transition from hospital to home based on Coleman’s “Transition Care Measures.”


Discharge starts at the time of admission and the quality of the discharge is promoted by a comprehensive evaluation. We developed a discharge tool kit that is being used for patients ≥ 65 years old admitted to the hospitalist service. It has multiple components, some of which are initiated on admission: (i) a newly developed history and physical form (cues the admitting physician to consider geriatric domains and concepts), (ii) an interdisciplinary team work sheet (at the front of the chart; allows various team members to comment on the barriers to and facilitators of the safe discharge of the patient), (iii) medication appraisal (both home and inpatient regimens are reviewed by pharmacists who offer guidance and feedback), (iv) fax communication notifying primary providers of their patients' admission, and (v) a predis‐charge appointment at which the provider explains the hospital course, counsels the patient, answers questions, reviews recommended follow‐up, and signs as does the patient a “discharge contract.”

The study was designed as a nonrandomized 2‐group experiment comparing control and intervention periods. In addition to the data collection that occurred while patients were in the hospital, follow‐up phone surveys were conducted 3 and 30 days after discharge.


The control period confirmed that transitions from hospital to home have potential risks. Specifically, 31 % of patients (n = 114) disagreed or strongly disagreed that they were part of the decisions about their discharge, 63% did not know the potential problems related to their medications, 31% felt that they did not know whom to contact about problems with their medications, and 42% did not think their primary care physician knew what had happened during their hospital stay. Also, during the control period, the 30‐day readmission rate to our facility was 17% and to other facilities was 14%. The 30‐day revisit rate to the emergency department was 38%. Evaluation of the number of medication errors noted 3 days following discharge is ongoing.

Author Disclosure:

P. Dedhia, None; E. E. Howell, None; S. Kravet, None; J. Bulger, None; T. Hinson, None; R. Hess, None; E. Bass, None; S. Wright, None.

To cite this abstract:

Dedhia P, Howell E, Kravet S, Bulger J, Hinson T, Hess R, Bass E, Wright S. Enhancing the Transition from Hospital to Home for the Older Adult. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 76. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/enhancing-the-transition-from-hospital-to-home-for-the-older-adult/. Accessed April 10, 2020.

« Back to Hospital Medicine 2007, May 23-25, Dallas, Texas