PREVENTING READMISSIONS AND INCIDENT DELIRIUM IN ELDERLY (PRIDE) PROGRAM

Abstract

Background: Low cost intervention hospital based care models can reduce length of stay and decrease readmission rates of elderly patients, while improving patient care quality. Programs like Hospitalized Elder Life Program (HELP) and Coleman Care Transition Intervention© (CTI) have independently demonstrated better patient outcomes. Collectively, programs that improve outcomes do better with a comprehensive approach in primary prevention of delirium and providing safe transition of care. Design: PRIDE (Preventing Readmissions and Incident Delirium in Elderly), a Quality Improvement (QI) initiative derives its program themes from the Hospitalized Elder Life Program (HELP) and Coleman Care Transition Intervention © to prevent delirium and provide safe care transitions for elderly hospitalized patients. An electronic dashboard identifies elderly patients admitted at University Hospital, Cleveland Medical Center at risk for delirium and readmissions. Two fold interventions are then provided. Delirium prevention: Trained volunteers cognitively and functionally engage patients in structured activities adapted from HELP. Improve Care Transitions: A Patient Centered Health record (PRIDE Journal) empowers patients with selfmanagement tools to raise awareness on functional independence and medication self-management on discharge. Outcomes: Preliminary data shows improved outcome with reduced LOS (5.8 days vs 7.7 days, N=45), reduced readmission rates (9% vs 42 %, N= 45). 94% of patients endorsed improved self-management skills. The program also demonstrates better staff satisfaction in patient care. Conclusion: PRIDE program is able to demonstrate better quality of care for a hospitalized elderly patient and improve care transitions.