OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n 5121; intervention n 5118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank w 2 55.0, P 5.026; Cox regression incidence density ratio 51.65, 95% confidence interval 51.13‐2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P 5.047) and lower mean total costs ($7,636 vs $12,481, P 5.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, Po.05), physical dimension of quality of life (2 weeks, Po.01; 12 weeks, Po.05) and patient satisfaction (assessed at 2 and 6 weeks, Po.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes. J Am Geriatr Soc 52:675–684, 2004.

Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions—often the most vulnerable—transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions—a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we reco...

The Importance Of Transitional Care In Achieving Health Reform

An essential characteristic of advanced practice nurses is the use of theory in practice. Clinical nurse specialists apply theory in providing or directing patient care, in their work as consultants to staff nurses, and as leaders influencing and facilitating system change. Knowledge of technology and pharmacology has far outpaced knowledge of how to facilitate health behavior change, and new theories are needed to better understand how practitioners can facilitate health behavior change. In this article, the Integrated Theory of Health Behavior Change is described, and an example of its use as foundation to intervention development is presented. The Integrated Theory of Health Behavior Change suggests that health behavior change can be enhanced by fostering knowledge and beliefs, increasing self-regulation skills and abilities, and enhancing social facilitation. Engagement in self-management behaviors is seen as the proximal outcome influencing the long-term distal outcome of improved health status. Person-centered interventions are directed to increasing knowledge and beliefs, self-regulation skills and abilities, and social facilitation. Using a theoretical framework improves clinical nurse specialist practice by focusing assessments, directing the use of best-practice interventions, and improving patient outcomes. Using theory fosters improved communication with other disciplines and enhances the management of complex clinical conditions by providing holistic, comprehensive care.

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Integrated Theory of Health Behavior Change: background and intervention development.

Family caregivers are critical partners in the plan of care for patients with chronic illnesses. Nurses should be concerned with several issues that affect patient safety and quality of care as the reliance on family caregiving grows. Improvement can be obtained through communication and caregiver support to strengthen caregiver competency and teach caregivers new skills that will enhance patient safety. Previous interventions and studies have shown improved caregiver outcomes when nurses are involved, but more research is needed. There is more to be learned about the effect of family caregivers on patient outcomes and areas of concern for patient safety. Nurses continue to play an important role in helping family caregivers become more confident and competent providers as they engage in the health care process.

Supporting Family Caregivers in Providing Care

OBJECTIVES: To determine the effects of follow-up telephone calls (TFU) in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home, with regard to physical and psycho-social outcomes in the first three months post discharge. The effects of TFU will be compared to usual care or other types of hospital follow-up (e.g. TFU initiated by primary-care-based health professionals). The effects of TFU initiated/delivered by various health care professionals (e.g. nurse, MD, social worker, pharmacist, ...) will be assessed in subgroup analyses. Although we expect to find that most TFU interventions will focus on outcomes such as reassurance and informational needs, we will include other types of outcomes because of the great variety of postdischarge problems. THE FOLLOWING QUESTIONS WILL BE ADRESSED: Primary Outcomes:
What are the effects of TFU initiated by a hospital-based health professional, on the psycho-social health (uncertainty, anxiety, informational needs, mood, perceptions of coping, quality of life, social activity) of patients in the first three months post discharge, compared to usual care or other types of hospital follow-up?; What are the effects of TFU on the physical health (activities of daily living, self-care abilities, self efficacy, independence) of patients in the first three months post discharge compared to usual care or other types of hospital follow-up?. Secondary Outcomes:
What are the effects of TFU on adherence of patients to recommended care in the first three months post discharge compared to usual care or other types of hospital follow-up?; What are the effects of TFU on patient knowledge regarding disease or symptom management in the first three months post discharge compared to usual care or other types of hospital follow-up?; What are the effects of TFU on adverse events (new morbidity, readmission) in the first three months post discharge compared to usual care or other types of hospital follow-up?; What are the effects of TFU on service utilization (health care services) in the first three months post discharge compared to usual care or other types of hospital follow-up? FACTORS INFLUENCING OUTCOMES: Intervention-related factors: Does the structure/format of the TFU influence the outcomes?; Does the type of health care provider (e.g. doctor, nurse, social worker, ...) of the TFU influence the outcomes?; Does the timing of the TFU influence the outcomes?; Does the frequency of the TFU influence the outcomes?; Do discharge planning activities and/or aftercare interventions other than the TFU influence the outcomes?. Patient-related factors: Does the age of patients influence the effects of TFU?;
Does the length of hospital stay influence the effects of TFU?; Does the medical diagnosis or procedure, carried out prior to discharge, influence the effects of TFU?; Do disease severity and co-morbidities influence the effects of TFU?;
Does the person's home living arrangements (living alone, living with someone) influence the effects of TFU?; Does the gender of patients influence the effects of TFU?. Other related factors: Does the country influence the effects of TFU?;
Does the type of hospital influence the effects of TFU?; Note: throughout this protocol the term 'patient' is used; although we recognize that terms such as 'consumer', 'client', or 'person with ... condition' may be more accurate than 'patient' and preferred by consumers themselves, we think that 'patient' remains the term that is most well known internationally to denote a person that is or has been in contact with a health professional for a certain condition.
CRITERIA FOR CONSIDERING STUDIEDS FOR THIS REVIEW: Types of studies: randomised controlled trials;
controlled trials. Types of participants: all patients discharged from an acute hospital setting (including emergency departments and one-day-stay procedures) to home (including a relative's home but excluding nursing homes or convalescence homes); all ages. Types of intervention: Experimental intervention: Telephone follow-up (TFU) initiated by a hospital-based health professional (medical, nursing, social work, pharmaceutical, (...) to a patient who is discharged to his/her own home setting (including a relative's home). The TFU has to be performed at least once within the first month after discharge. The TFU may have any kind of structure: for instance completely open ('how are you doing?') or completely structured. The TFU may contain one or more elements such as gathering of information, giving reassurance, giving advice on several topics, counseling, referral where required, etc. The TFU has, in principle, to be targeted to the patients themselves. In cases where the patients themselves are not able to talk on the phone (e.g. very young children, very sick people, patients with severe Alzheimer's disease) on one or more occasions when the TFU is delivered, these studies will be included. On the data-extraction sheet we will note the extent to which the TFU was indirect, and we will conduct separate analyses for studies in which the intervention for the entire research population was delivered directly to the patients, and for studies in which the TFU was (partly) delivered to relatives/caregivers. Studies in which the TFU is intended primarily to address the problems of caregivers rather than of patients, will be excluded. The TFU may be delivered as the only aftercare intervention, or may be part of a multi-component discharge planning or aftercare intervention; Control intervention: Usual care or other types of hospital follow-up.
TYPES OF OUTCOME MEASURES: Psycho-social health of patients: 1. uncertainty; 2. anxiety; 3. informational needs;
4. mood; 5. coping; 6. quality of life; 7. social activity. Physical health of patients: 8. level of activities of daily living (ADL)/functional status; 9. self-care abilities; 10. self efficacy; 11. independence. Other consumer oriented outcomes:
12. treatment adherence; 13. knowledge of disease and symptom management; 14. adverse events (complications, infection, readmission). Health service delivery oriented outcomes: 15. hospital readmission; 16. health services utilization. The outcomes must be measured at least once within the first three months post discharge. Since there is no generally-accepted definition of what a postdischarge period means, and the duration of postdischarge problems may vary for different illnesses and treatment procedures, the choice of a time period for study must be arbitrary. However there is evidence, as stated earlier, that most postdischarge problems occur in the period immediately after discharge. Moreover three months is a period for which it is reasonable to assume that outcomes can be related to the intervention in the first month after discharge; it is not likely that if no-effect were found in this immediate postdischarge time frame, effects would be found later . No restrictions will be made with regard to the measurement tools used, but psychometric properties will be recorded. This review will be limited to outcomes in patients themselves; possible outcomes in carers or
relatives will not be included. (aut. ref.)

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Telephone follow‐up, initiated by a hospital‐based health professional, for postdischarge problems in patients discharged from hospital to home

This chapter reviews 94 published research reports on transitional care of older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE, CINAHL, HealthSTAR, Sociological Abstracts and PsycINFO using combinations of the following search terms: transitional care, discharge planning, care coordination, case management, continuity of care, referrals, postdischarge follow-up, patient assessment, patient needs, interventions, and evaluation. Reports were included if published between 1985 and 2001, if conducted on samples age 55 and older, if relevant to nursing research, and if published in English. Intervention studies had to have a control or comparison group and a test for statistical significance. Four key findings from this review were identified. A high proportion of elders and their caregivers report substantial unmet transitional care needs, with the need for information and increased access to services consistently among the top priorities. Differences in expectations between and among patients, families, and health care providers, and the need for increased patient and family involvement in decision making, are common themes in discharge planning studies. Gaps in communication have been identified through the discharge planning process. Evidence about the effects of innovations in transitional care on quality and cost outcomes is sparse. Four main recommendations are made. Differences in older adults' transitional care needs based on race, ethnicity, and educational level, with attention to potential disparities, require further study. Studies of strategies to promote effective involvement of patients and families in decision making throughout discharge planning are needed. The development and testing of referral and other information systems designed to promote the transfer of accurate and complete information across sites of care should be a research focus. A priority for future research should be continued study of strategies to improve transitional care outcomes of older adults and their caregivers.

Naylor

Papers

Transitional care of older adults.