Effects of Comprehensive Follow-up Home Visits after Hospitalization on Functional Ability and Readmissions among Old Patients. A Randomized Controlled Study

Abstract

The aim was to examine whether regular interdisciplinary comprehensive home visits after discharge from hospital have an effect on the functional ability of elderly patients and on readmissions. The design is a prospective randomized and controlled study with outcome assessed 3 months after hospital discharge. The study includes 149 patients who were discharged to their homes from geriatric and medical wards. All patients were randomly assigned to receive either comprehensive geriatric assessment with follow-up by the interdisciplinary geriatric team at least five times during the first 6 weeks after discharge or the existing discharge procedures. The main outcome measures were functional ability and readmissions. The most important result is that the intervention had a beneficial effect on functional ability among patients who had been hospitalized at a medical ward. This was not the case among patients who had been hospitalized at a geriatric ward. In addition, there was a beneficial effect on functional ability among pulmonary patients and patients with fractures, but not among patients with cardiac failure. The results point at a need for the expertise of the interdisciplinary geriatric team in preparation of discharge among special groups of patients (e.g. home visit, contact to relevant persons in primary care, aids, etc.) and at a need for follow-up visits.