Learn More
Dementia and delirium, the most common causes of cognitive impairment (CI) among hospitalized older adults, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these older adults and their caregivers are particularly vulnerable to systems of care that either do not recognize(More)
Background. Hospitalization accounts for 70% of heart failure (HF) costs; readmission rates at 30 days are 24% and rise to 50% by 90 days. Agencies anticipate that telehomecare will provide the close monitoring necessary to prevent HF readmissions. Methods and Results. Randomized controlled trial to compare a telehomecare intervention for patients 55 and(More)
This study demonstrates that telehomecare is an effective way to improve patient education and self-management outcomes. The cost effectiveness of this technology makes it an attractive medium for reaching patients who require close monitoring, reinforced teaching, and reassurance. telehomecare can also support caregivers and connect socially isolated(More)
A new survey instrument was developed and validated to measure clinician (nurse) satisfaction with electronic health record impact on clinical process. The Health Information Technology Reference-Based Evaluation Framework guided the selection of evaluation dimensions for the survey. Survey questions were gathered from existing health information technology(More)
Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in(More)
OBJECTIVES Describe the characteristics of hospitalized older adults who were not referred for home care, compare the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care, and compare the characteristics of hospitalized older adults who did not receive a home care referral with patients(More)
OBJECTIVES Advance knowledge about changes in multiple dimensions of health related quality of life (HRQoL) among older adults receiving long-term services and supports (LTSS) over time and across settings. DESIGN A prospective, observational, longitudinal cohort design. SETTING Nursing homes (NHs), assisted living facilities (ALFs), community. (More)
OBJECTIVE To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness. METHODS A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who(More)