A collaborative study between researchers at UNSW Medicine’s Centre for Healthy Brain Ageing (CHeBA), the Department of Aged Care, St. George Hospital, and Calvary Health Care has developed an intervention for nursing home residents following hospital discharge which has resulted in almost two-thirds fewer hospital re-admissions.

The findings, which were published in the March issue of JAMDA, highlight the importance of follow-through care of nursing home patients after hospital discharge, an aspect of care generally neglected in this group.

Lead author on the paper and senior lecturer at UNSW and senior staff specialist at St. George and Calvary Hospitals, Dr. Nicholas Cordato, said that re-hospitalization of nursing home residents is frequent, costly, potentially avoidable, and associated with poor survival and diminished quality of life.

“Lack of specialist clinical input within facilities is a key factor,” said Dr. Cordato.

Mindful of these issues, the collaboration developed the Regular Early Assessment Post-Discharge (REAP) intervention of coordinated specialist geriatrician and nurse practitioner evaluation and management of nursing home residents who have been recently discharged from hospital.

The intervention consists of seven regular monthly conjoint geriatrician and nurse practitioner nursing home visits of nursing home residents for the first 6 months following hospital admission. The randomized, controlled study examined the effectiveness of the REAP intervention, with researchers identifying significant benefits associated with the implementation of REAP.

Co-author on the study and co-director of UNSW’s Centre for Healthy Brain Ageing, Professor Henry Brodaty said that the findings were extremely positive with almost two-thirds fewer hospital re-admissions and half as many emergency department visits compared with controls.

“Importantly, the total costs were 50% lower in the REAP intervention group, with lower total hospital inpatient and total emergency department costs,” said Professor Brodaty.

According to Dr. Cordato this research intervention has significant implications on the way in which health care is delivered to this vulnerable subset of our society.