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Introduction The social and economic conditions of where people live has been associated with HF hospital readmission. Multidisciplinary transitional care is effective to decrease HF readmission, but the impact of neighborhood disadvantage on transitional care is unknown. Early provider follow-up and nursing care coordination have unique contributions to transitional care and HF outcomes. The purposes of this study were to examine the relationship between early provider follow-up, nursing care coordination, and hospital readmission in a population of older adults with HF, and determine if an interaction exists with neighborhood disadvantage. Hypothesis There is a direct relationship between early provider follow-up and decreased HF readmission and an indirect relationship through nursing care coordination intensity that is moderated by neighborhood disadvantage. Methods A retrospective, correlational design utilized existing data. Data were from medical records and billing databases. Home addresses from index admissions were geocoded to census block groups and linked to the 2015 Area Deprivation Index database. Logistic regression was used to compare patients by readmission and early provider follow-up status. Moderated mediation analysis included ordinary least squares regression, logistic regression, and bootstrap confidence intervals to test the hypothesis. Results Of 1280 subjects, mean (SD) age was 79 (8.66) years, 50.7% were female, and 25.9% were non-white. In multivariable analysis, early provider follow up decreased the odds of readmission (OR 0.70 [CI, 0.50, 0.97], p=.032) and having 2 care coordination contacts increased the odds of readmission (OR 1.67 [1.07, 2.60], p=.024). Neighborhood disadvantage decreased the odds of having an early provider visit (OR 0.67 [0.49, 0.93], p=.015) and having a care coordination contact within 3 days of hospital discharge increased the odds of a provider visit two-fold (OR 2.13 [1.67, 2.72], p Conclusions Neighborhood disadvantage influences participation in transitional care interventions for the elderly HF population. An interventional study that examines the combined effect of care coordination and provider follow-up on HF readmission, using innovative processes to reach the most disadvantaged populations is needed. |
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