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At least 55 records · Page 3Linked to original sources
PubMed2004

Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial.

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=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.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.

Black or African American↗
PubMed2004

A transitional care service for elderly chronic disease patients at risk of readmission.

BACKGROUND: Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. OBJECTIVE: To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. DESIGN: A quasi-experimental controlled trial. SETTING: A large tertiary metropolitan teaching hospital. PARTICIPANTS: 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. INTERVENTION: Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. MAIN OUTCOME MEASURES: Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. RESULTS: There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. CONCLUSION: The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

Aged↗
PubMed2005

Health care transition: youth, family, and provider perspectives.

OBJECTIVE: This study examined the process of health care transition (HCT) posing the following questions: What are the transition experiences of youths and young adults with disabilities and special health care needs, family members, and health care providers? What are promising practices that facilitate successful HCT? What are obstacles that inhibit HCT? METHODS: A qualitative approach was used to investigate these questions. Focus group interviews were conducted. Content and narrative analyses of interview transcripts were completed using ATLAS.ti. RESULTS: Thirty-four focus groups and interviews were conducted with 143 young adults with disabilities and special health care needs, family members, and health care providers. Content analysis yielded 3 content domains: transition services, which presents a chronological understanding of the transition process; health care systems, which presents differences between pediatric and adult-oriented medicine and how these differences inhibit transition; and transition narratives, which discusses transition experience in the broader context of relationships between patients and health care providers. CONCLUSION: This study demonstrated the presence of important reciprocal relationships that are based on mutual trust between providers and families and are developed as part of the care of chronically ill children. Evidence supports the need for appropriate termination of pediatric relationships as part of the transition process. Evidence further supports the idea that pediatric and adult-oriented medicines represent 2 different medical subcultures. Young adults' and family members' lack of preparation for successful participation in the adult health care system contributes to problems with HCT.

Adolescent↗
PubMed2004

Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention.

OBJECTIVES: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates. DESIGN: Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235). SETTING: A large integrated delivery system in Colorado. PARTICIPANTS: Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions. INTERVENTION: Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach. MEASUREMENTS: Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects' care experience was assessed using the care transitions measure. RESULTS: The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28-0.96) at 30 days, 0.43 (95% CI=0.25-0.72) at 90 days, and 0.57 (95% CI=0.36-0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen. CONCLUSION: Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.

Aged↗
PubMed1977

Transitional care: a new approach to aftercare.

The transitional-care program incorporates the principles of behavior modification and group and family therapy in order to help recently discharged psychiatric patients maintain the positive changes that occurred in the hospital. Patients meet for approximately three hours a week, for up to 12 weeks, with nursing staff who worked with them while they were hospitalized. Each patient has an individual treatment program and goals, and during meetings with his team he discusses his progress and problems in meeting those goals. Staff members encourage patients to accept responsibility for each other and not to become too dependent on them. The program has been successful in preventing rehospitalization.

Adolescent↗
PubMedDate not supplied

Quality and cost outcomes of transitional care.

Longitudinal analysis of the outcomes of a transitional care program documented success in discharging patients home with remarkable compliance to discharge plans and sustained improvement in mental status and functional independence. Inpatient costs were significantly reduced.

Activities of Daily Living↗
PubMed2003

Transitioning care of the pediatric recipient to adult caregivers.

The development of transitional care is one of the major challenges for the twenty-first century as the survival rates and medical outcomes for child and adolescent recipients of solid organ transplants continue to improve. Such developments must include pediatric and adult care providers and require training of professionals in both arenas. Transition is a process in which the transfer to adult care is only one event within that process. The key elements of transition for pediatric recipients are discussed, and the importance of a coordinated, structured, multidisciplinary approach involving the adolescents themselves is highlighted.

Adolescent↗
PubMed2006

Growing up and moving on in rheumatology: development and preliminary evaluation of a transitional care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis.

This article describes the development and initial evaluation of an evidence-based transitional care programme recently implemented in a multicentre controlled trial in the United Kingdom. The individual components of the programme are described. Evaluation of the acceptability and utilization of these components employed questionnaires administered to users (adolescents with juvenile idiopathic arthritis and their parents) and providers (rheumatology health professionals). The results confirm the acceptability and utilization of the programme components in addition to further innovative developments during the course of the study. In conclusion, the evidence-based transitional care programme components reported here are acceptable and useful to both user and provider and are potentially feasible in clinical practice in a revised format.

Adolescent↗
PubMed2000

A decade of transitional care research with vulnerable elders.

This article describes the contributions to knowledge development and clinical practice during the past decade resulting from testing and refining a transitional care model with hospitalized elders by a multidisciplinary research team. A major goal of this research program has been to improve the postdischarge outcomes of older adults admitted to hospitals for an acute exacerbation of a chronic cardiovascular illness. In addition to demonstrating positive outcomes for elders while reducing costs, findings from the testing of the transitional care model have advanced knowledge of important patient and caregiver issues including the effects of the model of elders with medical versus surgical conditions, the profile of elders at risk for poor outcomes, predictors of caregiver burden, the unique needs of elders and the contributions of advanced practice nurses in meeting these needs, and decision making regarding home care referrals.

Aged↗
PubMedDate not supplied

The challenge of transitional care for young people with life-limiting illness.

Transitional care for young people with life-limiting illness is a particularly complex issue. The process of moving from paediatric to adult services is often fraught and poorly planned. As a result, this can add to the distress experienced by the young people and their families. The ideal would be to have a dedicated service for young adults that bridges the gap in care. The continued slow growth of community children's nursing services, however, highlights the constraints in developing services for a relatively small percentage of the population. Healthcare professionals must recognize the specialist needs of this patient group, and develop strategies to ensure that young people receive the care to which they are entitled.

Adolescent↗
PubMedDate not supplied

[Diabetes mellitus and the health care transition].

To document the existence of an epidemiologic and a health care transition in Mexico, diabetes mellitus (DM) mortality was analyzed. Age and sex adjusted mortality rates were estimated for each one of the states of Mexico, as well as the mean age at death, the number of years of potential life lost, and their percent distribution. The geographic distribution of these variables was plotted in maps according to tertiles or quartiles. The proportion of deaths due to acute and chronic complications of DM was classified according to community size. Polarized patterns of DM mortality as well as in the percentage contribution of deaths due to its acute and chronic complications were observed, in agreement with the postulated transitional process.

Acute Disease↗
PubMed2000

Enhancement of a pharmacy consultation program on a transitional care unit.

The revision and outcomes of a pharmacy consultation program on a transitional care unit (TCU) are described. In 1996, the pharmacy consultation program for the TCU at a 550-bed, tertiary care, community teaching hospital was revised. The changes included increasing the number and depth of medication reviews, mandating pharmacist attendance at interdisciplinary meetings, simplifying the medication review form, and expanding physician education. Data collected during the final two years of the original program (May 1994 to April 1996) and the first two years of the revised program (July 1996 to August 1998) were compared. The number of drug-related problems identified per admission was 0.80 for the revised program (versus 0.32 for the original program), the percentage of patients receiving at least one pharmacy medication review was 99% (versus 70%), the number of pharmacist recommendations made was 726 (versus 140), and the percentage of recommendations accepted was 82% (versus 55%). The program required up to 15 hours of pharmacist time per week. Cost savings were estimated at $15,000 for the first year of the revised program and $23,000 for the second year. Revision of the pharmacy consultation program for a TCU increased the identification of drug-related problems and the number of pharmacist recommendations, helped integrate pharmacists into the interdisciplinary care team, and produced a modest estimated cost savings.

Data Collection↗
PubMed2004

The effectiveness of a nurse-led transitional care model for patients with congestive heart failure.

This research brief reports on a study that evaluated the effectiveness of a transitional care model for patients with congestive heart failure (CHF). The model focused on improving the transition from hospital to home care by upgrading traditional discharge practices and implementing an evidence-based educational program. It used usual care nurses, rather than specialist nurses, to carry out the intervention. The study found that health-related quality of life improved and the number of emergency room visits was reduced.

Journal Article↗
PubMed1999

Ambulatory care transitioning for the rural hospital.

As rural community hospitals continue their transition of health care delivery to predominantly outpatient and ambulatory services, many factors are being considered in design, planning, and operations to enact this change both efficiently and effectively. The following examines strategies that allow these changes to be incorporated successfully while maintaining the flexibility for the continued transition that these organizations will experience in the future.

Ambulatory Care Facilities↗
PubMed1997

Transitional care: bridging the gap.

As hospitals redesign into integrated delivery systems, new services and linkages to support patients across the care continuum become necessary. The implementation and outcomes of a transitional care program are discussed and evaluated.

Continuity of Patient Care↗
PubMed2006

A qualitative exploration of a patient-centered coaching intervention to improve care transitions in chronically ill older adults.

Persons with chronic illness frequently find they need to navigate the health care system but are ill equipped to do so. Using interview data from 32 participants, this study explored patients' experiences with a coaching intervention that provided patients with support and tools to enhance self-management during care transitions. The findings suggest the efficacy of the model in enhancing self-management, particularly because it fostered the perception of a caring relationship, leading to greater patient investment in the program. Future research should seek to explore which patients are most ready and able to benefit from this type of intervention.

Aged↗
PubMed2026

Process evaluation of a nurse-led transitional care model (Cardiolotse) within a randomized controlled trial aiming to improve care coordination for patients with cardiovascular diseases in Germany.

BACKGROUND: Patients with higher age suffering from cardiovascular disease discharged from hospital are at greater risk of readmission within 30&#x2009;days. We evaluated an innovative care program providing post-discharge support and helping patients to navigate through the healthcare system. This paper reports the findings of the process evaluation of the randomized controlled trial Cardiolotse, a nurse-led transitional care model improving care coordination for patients with cardiovascular diseases in Germany. METHODS: A process evaluation, following the guidelines of the Medical Research Council (MRC) Framework, was performed. Semi-structured interviews with all relevant target groups were conducted to gain more insight about implementation processes. Questionnaires and medical records were used to explore mechanisms of impact and understand how change was produced in the intervention. Qualitative data were analysed using content analysis with deductive and inductive categories. Descriptive statistics and subgroup analyses were utilized to explore quantitative data. RESULTS: Overall, the designed training programme was perceived positively by the study nurses, so called Cardiolotsen (CLs). Patients receiving support by the CLs reported positive satisfaction ratings. Interactions between CLs and patients were reported as trustworthy and reliable. A total of approximately 12,500 contacts were made over the course of the intervention. However, changes in satisfaction scores between intervention and control groups in terms of medical treatment or the interaction between medical health providers involved in the treatment could not be determined. Furthermore, data suggested reach issues with respect to office-based physicians, as regular CL contact could not be achieved with 90% of the participating general practitioners and cardiologists. CONCLUSIONS: The CLs served as an important source of support for the participating patients throughout the intervention. At regular intervals, they checked a patient's health status and their adherence to therapies after discharge. However, the process evaluation identified cross-sectoral communication and information exchange between CLs and office-based physicians as an implementation challenge. TRIAL REGISTRATION: The study was retrospectively registered at German Clinical Trial Register, http://www.drks.de/DRKS00020424 (Trial Registration Number DRKS00020424) on 18 June 2020.

Humans↗