A new type of intervention for nursing home residents following hospital discharge has resulted in almost two-thirds fewer readmissions.

The intervention is a result of a collaborative study between researchers at UNSW Medicines Centre for Healthy Brain Ageing (CHeBA), the Department of Aged Care, St George Hospital and Calvary Health Care.

Lead author, senior lecturer at UNSW and senior specialist at St George and Calvary Hospitals, Dr Nicholas Cordato said the re-hospitalisation of nursing home residents is frequent, costly, potentially avoidable and associated with poor survival and diminished quality of life.

Of particular importance in addressing this issue was the follow through care of nursing home patients after discharge, an aspect of care generally neglected.

“Lack of specialist clinical input within facilities is a key factor,” said Dr Cordato.

Consequently, a Regular Early Assessment Post-Discharge (REAP) intervention was developed.

The team consists of a nurse practitioner and a specialist geriatrician who evaluate and manage nursing home residents who have recently discharged from hospital.

The team make seven regular monthly nursing home visits for the first six months following hospital admission.

The randomised controlled study examined the effectiveness of REAP intervention, with researchers identifying significant benefits associated with the implication of REAP.

Co-author of the study and co-director of UNSW’s CHeBA, Professor Henry Brodaty, said the findings were extremely positive with almost two thirds fewer hospital readmissions and half as many emergency department visits than the controls.

The findings were published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA).