Paul Anthony Ashton BSc (Hons) Psychology is Assistant Research Psychologist Memory Assessment and Research Centre (M.A.R.C.), Moorgreen Hospital, , Southampton,ABSTRACT Ashton, P. et al (2006) The effect of locality link nurse intervention on elderly psychiatric hospital readmission rates www.nursingtimes.net
ABSTRACT Ashton, P. et al (2006) The effect of locality link nurse intervention on elderly psychiatric hospitalreadmission rates www.nursingtimes.net
AIM: The purpose of this study was to investigate whether visits to a patient early post-discharge by a memberof the ward team (the locality link nurse or LLN) reduces elderly psychiatric hospital readmission rates and improves thephysical and psychological state of the patient.
METHOD:A randomised control independent samples design was used to acquire data from 25 elderly psychiatricpatients in regard to levels of physical and psychological health before discharge and at six weeks post-discharge. Hospitalpsychiatric readmissions for each participant were recorded for 365 days following initial discharge. The data was analysedusing SPSS 12.0. RESULTS:Short-term LLN intervention does not reduce psychiatric hospital readmission rates or influencephysical and psychological health, rather a trend suggested that those who received LLN intervention were more likely to bereadmitted to hospital.
CONCLUSION:One link nurse visitation two weeks post-discharge is not an effective solution to reduce hospitalreadmissions and prevent the Ã?Â?revolving door syndromeÃ?Â' in elderly psychiatric patients. However, thesmall sample size affects the statistical power to find an experimental effect. Future research that recruits a larger cohortof participants and provides frequent and durable intervention, with multi-disciplinary collaboration and more detailedanalysis of variables, could result in a resolution to the Ã?Â?revolving doorÃ?Â' problem both for thepatient and the National Health Service.
Repeated hospitalisation in older adults is detrimental both for the patient and the National Health Service (NHS).Studies have shown that approximately 20Ã?Â-22% of older patients are readmitted to the hospital within 60 days ofinitial discharge, with 33Ã?Â-44% being readmitted in the subsequent one to three years (Miller et al, 2001).
Victor and Vetter (1988) suggest that admission to hospital for the elderly is disorientating, resulting in them losingcontact with services received before admission, and discharge home may be equally as traumatic. Research has highlighted thatolder people who are readmitted are more severely ill and more functionally dependent than during their first admission(Berkman et al, 1992).
The sequelae of first and recurrent hospitalisation may lead to a self-perpetuating cycle Ã?Â- labelled theÃ?Â?revolving door syndromeÃ?Â' Ã?Â- of readmissions. In light of this, rehospitalisation candramatically drive up healthcare expenditure with the cost of a readmission accounting for up to 60% of hospital expenses(Weinberger et al, 1996).
The issue of elderly Ã?Â?revolving doorÃ?Â' patients is therefore of paramount importance both for theeconomics of the NHS and the quality of life for the patient. Cost and quality implications deem it essential that thereadmission phenomenon is further investigated to enable service providers to identify patients at risk and develop anintervention that will ensure the delivery of quality care to service-users.
It is thought that a significant number of readmissions are avoidable and potentially preventable (Frankl et al, 1991). Anadequate plan must address the medical and the psychosocial needs of post-discharge patients (Morrow-Howell et al, 1991).Although readmissions can occur for a variety of reasons, a high emergency readmission rate may suggest that the level ofsupport provided in the community is inadequate.
With the rapid growth of the elderly population and the decreasing number of days that patients are able to remain in thehospital, the task of discharge planning has become increasingly critical and challenging (Cummings, 1999). Over the past 20years many research studies have drawn repeated attention to the problems that can be experienced by patients and theirfamilies in the process and aftermath of discharge from hospital (Tierney et al, 1994).
Research has highlighted: the shortcomings in terms of poor communication between hospital and community (Williams et al,1992); lack of assessment and planning discharge; inadequate notice of discharge (Neill and Williams, 1992); inadequateconsultation with patients and their carers (Klopp et al, 1991); over-reliance on informal support and lack of (or slow)statutory service provision (Williams and Fitton, 1991); and inattention to the special needs of the most vulnerable, such asthe frail elderly (Neill and Williams, 1992).
Discharge planning is a major concern of hospitals as they seek to reduce costs associated with prolonged lengths ofhospital stay, prevent subsequent readmissions, and ensure that discharge dispositions are appropriate (Cox, 1996). Effectivedischarge planning can reduce both the length of hospital stays and subsequent readmissions (Andrews, 1986).
Rehabilitation and the process of discharge after an episode of acute illness requiring hospitalisation are receivingever-increased attention (Sinclair and Dickinson, 1998), with studies finding mixed results. For example, Vavouranakis et al,(2003) found that intensive home care of middle-aged patients with severe heart failure results in improved quality of life anddecreased hospital readmission rates.
Leiby and Shupe (1992) found that elderly patients followed for six months after hospital discharge who received homehealthcare had fewer hospital readmissions and fewer rehospitalisation days than those who did not receive home healthcare.Other researchers have found similar results whereby as the number of home healthcare visits increase, the number of hospitalreadmissions decrease (Ashton et al, 1986; Dennis et al, 1996). However, Elkan et al (2001) found no effect of home-visitingprogrammes on admissions to hospital. Furthermore, Victor and Vetter (1985) found that elderly non-psychiatric patients weremore likely to be readmitted if they had seen a district nurse or health visitor. In addition, readmitted patients have asignificantly higher use of home helps and day-hospital visits.
Haastregt et alÃ?Â's (2000) review of 15 studies of home visitation by public health nurses of elderly peopleliving in the community concluded that no clear evidence exists for the effectiveness of the visits. The observed effects wereconsidered to be fairly modest and inconsistent. The inconsistencies in results may be explained by the underlying factors thataffect an individualÃ?Â's likelihood to be readmitted, including the natural history and severity of the underlyingcondition, social factors such as social and economic status, cultural background, lack of social and family support, anddeficiencies in the local healthcare system (Surber et al, 1987).
The rate of readmission is sometimes used as an indicator of discharge practice performance and targets to reduce thisrate have been set by the UK government (Department of Health, 2000). With the increasing importance of liaison betweenhospital and community staff in the process of discharge (Tierney et al, 1994), and inconsistent findings with regard to theeffectiveness of home help interventions in previous research, different approaches to this problem need to be investigated.
With this in mind the position of locality link nurse (LLN) was developed from existing mental health nurses working on anacute psychiatric ward of a UK community hospital who have built a relationship with the patient. The main objective of thepresent study was to investigate whether the introduction of a LLN may be an effective way of supporting the patientpost-discharge and reducing hospital readmission rates.
The role of the LLN would be to provide largely practical and psychological support by ensuring that care needs andbarriers to continued psychological and physical well-being, for example, compliance to medication and patient needs, areaddressed early post-discharge. It was hoped this may help to develop and maintain the patientsÃ?Â' practical,physical and mental skills.
The LLN would be at a unique advantage as they would have already developed a therapeutic relationship with the patientduring their initial hospital admission and be able to continue this relationship in the community.
A randomised control independent samples design was used to investigate whether early post-discharge link nurseintervention reduces hospital psychiatric readmission rates in the elderly.
An opportunity sample of 25 elderly patients (mean age = 77.76, range = 68-91), 32% being male, with a primary ICD 10diagnosis of functional psychiatric illness were invited to participate in the study by the link nurse while admitted on thefunctional psychiatric ward of a UK community psychogeriatric hospital.
A questionnaire was constructed to provide information regarding the patientÃ?Â's personal details,demographical information, medical history, medications, social circumstance, and level of community support by healthcareprofessionals. The mini mental state examination (MMSE) was used to measure the cognitive state of the patient; it consists ofa 30-item scale which has been shown to be a valid measure of cognition in the elderly (Folstein et al, 1975). The geriatricdepression scale (GDS) was used to measure depression and is a reliable and valid 30-item depression screening scale forelderly populations (Yesavage et al, 1982-83). The Camberwell assessment of need for the elderly (CANE) is a psychometricallyaccepted instrument that consists of a 24-item scale (plus two items for carer needs), measuring the needs of older people withmental disorders (Reynolds et al, 2000).
The sample was randomly assigned using a number system by a blinded administrator to receive follow-up by LLN within twoweeks of discharge or no follow-up by LLN, both groups continued to receive community care by health care professionals as partof their normal clinical management. The study assessments were administered by the link nurse during the last week of eachpatientÃ?Â's admission on the psychiatric ward, and at six weeks post-discharge at the participantÃ?Â'shome. Information relevant to medical history, medications, social circumstance and level of community support were obtainedfrom both discussion with the participant and analysis of their medical notes. ParticipantsÃ?Â' psychiatricreadmission rates were recorded for up to one year post-index discharge.
The data were analysed using SPSS 12.0. Independent samples t-test (two-tailed) was used for parametric analysis of therelationship between early link nurse follow-up and change in pre and post discharge MMSE, GDS, and CANE scores. A negativechange in MMSE scores will indicate deterioration in cognitive functioning. A negative change in GDS scores will indicate animprovement in depression, and a negative change in CANE scores will indicate having fewer needs. Mann-Whitney U test(two-tailed) was used for non-parametric analysis of the relationship between early link nurse follow-up and hospitalpsychiatric readmissions. The relationship between dichotomous variables was explored using chi-square tests.
The sample consisted of eight males and 17 females with a mean age of 78 years old (range = 68Ã?Â-91). Of these,72% were living alone and 88% had family support. For 44% of the sample a social worker and community mental health nurse(CMHN) was involved in their care, while 16% of the sample did not receive any community care from a social worker or CMHN. Asocial worker solely provided community care for 4%, and a CMHN solely provided care for 36% of the sample. Within the sixmonths preceding study enrolment 40% of the sample had been admitted on to a psychiatric hospital ward. Some participants hadbeen enrolled on to the study within the previous 364 days, therefore information regarding psychiatric hospital readmissionsover the past whole year was only available for 68% of the sample, with the mean number of days since entry onto study being316.12. During the first year post-index discharge, 44% of all participants were readmitted on to a psychiatric hospital ward.
Independent samples t-test were conducted to investigate the relationship between early link nurse follow-up and change inpre and post-discharge MMSE, GDS and CANE scores, Mann-Whitney U test was conducted to investigate the relationship betweenearly link nurse follow-up and hospital readmissions (Table 1), and the chi-square test was conducted to investigate therelationship between early link nurse follow-up or no follow-up and the presence or absence of a hospital readmission (Table2).
Table 1. Link nurse follow-up and number of hospital readmissions over
first year post discharge (READS = Number of hospital readmissions).
*Mann-Whitney U test
Table 2.Chi-Square test between follow-up or no follow-up and
hospital readmission or no hospital readmission (READ =
Yes (%) No (%)
8 (57) 3 (27)
6 (43) 8 (73)
14 (100) 11 (100)
There were no significant relationships between early link nurse follow-up and change in pre and post-discharge scores on the MMSE, GDS and CANE (Table 1), and no significant relationship between link nurse follow-up and hospital readmissions (Tables 1 and 2).
The findings of the present study suggest that the introduction of a LLN to provide early follow-up intervention in the community to recently discharged elderly psychiatric patients does not reduce hospital readmission rates. Although a trend was found in that those who had received early link nurse follow-up were more likely to have a hospital readmission in the subsequent year than those who had not received follow-up, this was not significant. LLN follow-up produced no significant change on scores of cognition, emotion, or the individual needs of elderly psychiatric patients.
A tendency towards declining cognition, enhanced mood, and less individual needs was found at six weeks post-discharge as compared to index assessment for both follow-up and no follow-up participants. Those who received no follow-up had the most prominent tendency for improvement on assessment of needs at six weeks post-discharge.
Previous research has shown that 33Ã?Â-44% of older patients are readmitted to hospital in the subsequent one to three years from discharge (Miller et al, 2001). The present results are consistent with this as 44% of the sample was readmitted within the subsequent one year of discharge. This supports the finding that one link nurse visitation at two weeks post-discharge was ineffective in reducing readmissions over the following year.
An improvement in physical and psychological disability would be expected to share an inverse relationship with hospital readmissions, as disability has been found to be significantly related to readmission rate (Stuck et al, 2002). The inability of link nurse intervention to reduce rehospitalisation is congruent with the observation of no significant change in cognition, depression, or individual needs for the follow-up group. It is an interesting finding that participants showed no significant deterioration or improvement in scores of cognition, emotion, and needs, given that they are recovering from a hospital in-patient stay which may have had detrimental effects on cognition, emotion, and individual needs (Mayo-Holloway and Pokorny, 1994).
Previous research looking at the relationship between the process of hospital discharge, community care, and hospital readmissions have shown mixed results. Although it is difficult to regard the present studyÃ?Â's intervention as community support, given the brief nature and aims of the visit, the results are in line with findings from studies of elderly non-psychiatric patients. For example, Victor and Vetter (1985), found a positive correlation between increased community support and hospital readmissions, and Haastregt et al (2000) and Elkan et al (2001), found no clear evidence of the effectiveness of health nurse visitation on hospital readmissions.
One of the key findings to come out of research into community care and readmission rates is that success in reducing hospital readmissions is produced by a multi-disciplinary, intensive support approach (Stuck et al, 2002).
Conclusion and recommendations
The present study provided a single one-hour LLN visitation at two weeks post-discharge. It is not likely that the intensity of this visitation would have provided adequate post-discharge care enabling the patient to remain at home with an improved state of health rather than having a relapse or developing a concomitant problem that requires rehospitalisation. Ideally, the link nurse intervention would highlight information on cognitive, emotional, and practical needs that require therapeutic intervention so that the physical and psychological well-being of the patient can improve and rehospitalisation does not occur. Therefore it is suggested that the link nurse works in closer conjunction with social services and community mental health teams in both facilitating the transfer from in-patient stay to community and identifying problem areas that require further clinical and community management.
A more intensive and enduring programme of link nurse intervention needs to be investigated. It should be mentioned that 84% of the sample had a social worker, a community mental health nurse, or both professionals involved in their care before discharge. This community care for a majority of the sample may have influenced the present findings rather more than the exclusive link nurse intervention.
As well as the LLN intervention being of a limited input, the other main limitation of this study was its power to detect a statistically significant effect due to the small number (25) of participants. Future studies should ensure an adequate-sized research cohort is investigated to provide suitable experimental power.
A longer study in which the number and duration of visits are variable to the needs of the patient may show significant positive results and offer a solution to the Ã?Â?revolving door syndromeÃ?Â'. The LLN could play a vital role in liaising between relevant multi-disciplinary teams, highlighting, and recommending intervention for identified problems.
This would hopefully lead to a reduction in readmission and the disorientating and detrimental effects associated with a hospital admission (Mayo-Holloway and Pokorny, 1994). Analysis should look at hospital readmissions over time in relation to each link nurse visitation, incorporating level and change of physical and psychological disability.
In summary, the present study has shown that one link nurse visitation two weeks post-discharge is not an effective solution to reduce hospital readmissions and prevent the Ã?Â?revolving door syndromeÃ?Â' in elderly psychiatric patients. However, the small sample size affects the statistical power to find an experimental effect. Future research that recruits a larger cohort of participants and provides frequent and durable intervention, with multi-disciplinary collaboration, and more detailed analysis of variables could result in a resolution to the Ã?Â?revolving doorÃ?Â' problem both for the patient and the National Health Service.
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