Deakin University

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Older Persons Complex Care Nurse Practitioner model to reduce hospital readmissions: A pilot study

journal contribution
posted on 2023-02-09, 21:32 authored by G Lowe, J Dohrmann, J Chapman, L Stamford, Andrea DriscollAndrea Driscoll
Background: People aged over 65 years are associated with increased numbers of co-morbidities, higher health care needs, an increased risk of fragmented care and are four times more likely to be hospitalised than those under 65 years. Nurse Practitioners (NP) working with older populations improved screening, clinical outcomes, patient satisfaction and provision of equal or better care for chronically ill patients. Aim: To evaluate the effectiveness of the NP within the Older Persons Complex Care service to reduce hospital readmission rates in older complex patients. Methods: A pre and post pilot study using a retrospective clinical audit of medical records of patients referred to the NP service from January 2018 to April 2019 was undertaken. All patients reviewed by the NP were eligible for inclusion in the study and only those patients reviewed by the NP were included. Findings: Seventy seven patients were referred during the reporting period. Ages ranged from 64 to 98 years, and many co-morbidities were reported; minimum of two and maximum of 15 highlighting the complexity of the cohort. Management included education (100%), diagnostics (62%), medication changes (61%) and referrals (49%). Discussion: Patients managed within the service had reduced hospitalisations and many medications were ceased, reduced or titrated by the NP. Education was a key component of care. Conclusion: The value of NPs in the provision of care to older persons with complex, chronic diseases was highlighted with the potential to reduce readmissions, improve quality use of medicines and safe prescribing.






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