Discharge Planning and Telehealth for Post CABG Elders

描述（由申请人提供）：

DESCRIPTION (provided by the applicant: A growing number of elderly patients are receiving coronary artery bypass graft (CABG) surgery; the most frequently performed major surgery and one of the most costly single treatments for coronary heart disease. Prevention of complications, including hospital readmissions are important, yet interventions that do not require costly home visiting to improve elders' outcomes after CABG are largely untested. Purpose: to examine the effectiveness of a Discharge /intervention for Cardiac Elderly (DICE). DICE consists of 1) focused reinforcement of the discharge plan, 2) home telehealth vital sign and weight monitoring, and 3) post-discharge telephone follow up of elderly cardiac surgery patients. Discharge/Intervention for Cardiac Elderly (DICE) Aims: using a 3 group (randomized to one of two interventions and control) design, determine (1) the effectiveness of DICE on the post hospitalization outcomes of functional status, health status, health care utilization (in terms of primary care physician and clinic visits, acute care visits, emergency room visits, and rehospitalizations), and satisfaction with care for elderly cardiac surgery patients at 1, 2, and 3 months after hospital discharge, (2) the cost effectiveness of DICE. Subjects: 330 patients age greater than 65 from 3 hospital sites. Design: 4 year randomized control trial. Intervention: DICE consists of 1) reinforcement of the discharge plan, 2) home based telehealth monitoring, and 3) post-discharge telephone follow up at 1 day, 3 days, and weekly for 4 weeks. Modified DICE consists of 1) reinforcement of the discharge plan, and 2) post-discharge telephone follow up at 1 day, 3 days, and weekly for 4 weeks. Implications: The proposed research represents a logical extension of the principal investigators research focus in studying outcomes for elderly patients, and the Co-Investigator's focus on studying the impact of telehealth interventions. The study serves to extend the research team's work to explore the effect of an intervention for high-risk elderly CABG surgery patients. The study will advance understanding of the outcomes of nursing interventions for elderly cardiac surgery patients at high risk for developing postoperative complications and explore the effect of the DICE intervention on improving elders' outcomes post CABG.