Abstract 126: Inside Transitional Care

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Background: Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) delivered transitional care program designed to provide cardiac patients a timely, guideline-based, first post-discharge visit. BRIDGE follow-up within 14 days of discharge has been shown to reduce early adverse events, including rehospitalization, for ACS patients, at a cost savings. Despite this success, there is little evidence documenting what occurs during these visits. The purpose of this study is to examine the content of first post-discharge visits.

Methods: Mixed methods design was used to examine content of BRIDGE visits and assess patient perceptions of rapport with their NP. Visits with 17 ACS patients were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis to identify themes within and across visits. Patients completed the Consultation and Relational Empathy (CARE) scale and a modified Patient-Doctor Relationship Questionnaire (PDRQ9). Demographic information and details of 30-day readmissions were abstracted from patient charts.

Results: Nineteen patients consented; 17 (89%) completed the study. Most were male (14, 73.7%) and white (15, 78.9%). Average age was 61.6 years. One (5%) had an unplanned readmission. NP priorities during visits included clinical history, medication reconciliation, patient education, and referrals. Patients were screened for guideline-driven secondary prevention queues such as physical symptoms, diet, physical activity, and smoking. Patient priorities included questions about daily life (can I play catch with my grandson); clinical questions (can a stress test cause a heart attack); feelings (he feels like dying; I feel helpless), and fear of death (I’m afraid if I go to sleep I might not wake up). On average, NPs contributed 59% of the verbal content of the visits. Patients felt highly connected with NPs (mean PDRQ9 43.05 + 3.1; possible range 5, 45, α=.95) and viewed them as deeply empathic (mean CARE 43.5 + 2.8); possible range 0, 50, α=.94).

Discussion: A qualitative approach resulted in nuanced understandings of the content of first post-discharge visits. Patients and NPs have overlapping priorities for these visits. Both concern themselves with managing the medical condition. In addition, patients reveal other priorities, such as how to carry on with daily life and manage feelings and fears. Notably, assessment of psychosocial issues and mental health were absent, suggesting an opportunity to enhance patient care. NPs may be ideally suited to begin filling this gap given their excellent rapport with patients and expertise in motivational interviewing. It is plausible that these factors also contribute to the success of the BRIDGE program in reducing 30-day readmissions. Further research is needed with larger sample sizes and other types of providers to fully assess their impact.

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