Results of a recent study published in the Journal of the American Medical Association reveal-surprise!-that older people with common medical and surgical problems who went from the hospital to their homes and received planned follow-up nursing care showed significant improvement.

Such treatment, the study maintains, also saved the health care system a bundle-Medicare reimbursement was about $600,000 lower for the 177 patients who received full follow-up care, a mean per-patient savings of about $3,000.

Supported by the National Institutes of Health's National Institute of Nursing Research, Bethesda, Md., the study, Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders, focused on 363 patients aged 65 and over who were assigned either to a transitional care group or a control group that received routine care. The transitional care plan involved clinical assessment, monitoring, management of symptoms, caregiver education and assistance, and information related to maintaining health. Nurses who prepared the patient for discharge also provided home follow-up care. Routine-care patients were left on their own to obtain further care.

Six months after being discharged, according to the study, only 20 percent of the transitional-care patients were rehospitalized compared with 37 percent of the routine-care group. Length of hospital stays was also less-1.53 days for the transitional group compared with 4.09 days for the routine group.