A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly

Prof Case Manag. Nov-Dec 2007;12(6):330-6; quiz 337-8. doi: 10.1097/01.PCAMA.0000300406.15572.e2.


Purpose: This article reviews 15 clinical trials of nurse-assisted case management intended to improve posthospital transitions of elderly patients to other settings.

Primary practice setting(s): Hospitals.

Methodology and sample: The trials were selected after a systematic search of the PubMed database for the period 1996 to 2006.

Results: Eight of the 15 interventions showed reduced hospital readmission rates and/or fewer hospital days. These findings were observed across patients with "all cause" and heart failure, a variety of hospital types, and variations in the intervention. Reductions in the use of emergency departments were observed in 3 of the 11 studies investigating this. Lower expenditures were reported by all 6 studies reporting such comparisons.

Implications for cm practice: Home visits/continuous contact with patients, early postdischarge and frequent contacts, patient education, and the use of specialized nurses who could offer appropriate training and coaching were often credited as program strengths.

Publication types

  • Research Support, N.I.H., Extramural
  • Review
  • Systematic Review

MeSH terms

  • Aftercare / organization & administration
  • Aged
  • Case Management / organization & administration*
  • Clinical Trials as Topic
  • Continuity of Patient Care / organization & administration
  • Emergency Service, Hospital / statistics & numerical data
  • Geriatric Nursing / organization & administration
  • Health Expenditures / statistics & numerical data
  • House Calls
  • Humans
  • Length of Stay / statistics & numerical data
  • Medicare / statistics & numerical data
  • Mortality
  • Nurse's Role*
  • Nursing Administration Research
  • Nursing Evaluation Research / organization & administration*
  • Outcome Assessment, Health Care / organization & administration*
  • Patient Discharge* / standards
  • Patient Discharge* / statistics & numerical data
  • Patient Education as Topic
  • Patient Readmission / statistics & numerical data
  • Research Design
  • Total Quality Management
  • United States