Home Evaluation and Assessment Team (HEART) for Hospital Transitions

Transfers among care settings are common and affect about one fourth of hospitalized older adults (AHRQ, 1999). Challenges in successfully transitioning patients between care settings have been documented in several research studies. During transition patients are at elevated risk of medication errors, duplication of care, unsafe transfers, and readmission. The HEART study is testing an innovative model within Kaiser Permanente aimed at improving patient transitions and reducing the rates of hospital readmissions among frail elderly. This model utilizes a Registered Nurse Practitioner (RNP) paired with a telephone support center to provide brief evaluation to identify patient needs, educate and train patients on self-management of their condition, and connect patients with the care modality most appropriate for their condition. Outcomes from this innovative model of care aim to result in an increase in the quality of care provided and received by the elderly but also improve satisfaction among clinical providers.

A total of 199 participants were enrolled in the HEART study from July 2006 through June 2007. Of these, 100 were randomly assigned to the intervention arm and 99 to usual care. Among those enrolled in the study, 67% were taking 7 or more medications, 61% had 1 or more ADL deficiency and 25% had had a hospital readmission in the last 30 days. Findings reveal those randomly assigned to the HEART intervention had a significant improvement in satisfaction with care (p=.002), self-efficacy in managing their health (p<.001) and a reduction in the use of the emergency room in the six months following hospital discharge (p= .07).