• Corpus ID: 6206404

Transitional care for older adults: a cost-effective model.

  title={Transitional care for older adults: a cost-effective model.},
  author={Mary D. Naylor},
  journal={LDI issue brief},
  volume={9 6},
  • M. Naylor
  • Published 1 April 2004
  • Medicine
  • LDI issue brief
Although the quality of care in hospitals and ambulatory settings is undergoing more scrutiny, far less attention has focused on the care patients receive as they move from one setting to another. Older patients who transition from hospital to home are particularly vulnerable: many of these patients have multiple health problems that continue beyond discharge. In response, investigators at the University of Pennsylvania developed a model of care delivered by nurse experts who follow vulnerable… 
The transitional care model (TCM): hospital discharge screening criteria for high risk older adults.
  • M. B. Bixby, M. Naylor
  • Medicine
    Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses
  • 2010
This evidence-based practice approach addresses needed hospital discharge assessment that should be completed by registered nurses or advanced practice nurse staff managing the complex care of hospitalized older adults.
Bridging the Gap in Transitional Care: A Closer Look at Medication Reconciliation
Gerontological nurses can play a key role in ensuring patient safety and preventing adverse drug events when they use the Medication, Background, Assessment, and Recommendations (MBAR) form during the handoff between shifts.
Current evidence regarding models of acute care for hospitalized geriatric patients.
Preliminary evidence suggests that all 3 models of acute care for elderly people may be effective at improving outcomes for hospitalized older people, but more rigorous research is needed to determine which programs are most effective atimproving clinical geriatric outcomes in different settings.
How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program
The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care, and is intended to enable a significant proportion of care recipients to return home.
Impact of Post-Acute Transition Care for Frail Older People: A Prospective Study.
Post-acute programs should not be targeted solely at fitter older people: those who are frail also have the potential to gain from community-based rehabilitation.
An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions
Mobile Integrated Healthcare is an emerging model focused on closing care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.
Care transitions in a changing healthcare environment
Although no specific strategy at discharge has proven to be effective in reducing readmissions, practices that include good posthospital communication to the patient and care team, access to follow-up, and attention to mobility and self-care deficits are important factors in limiting readmissions.
The Model of Care Partner Engagement: use in delirium management.
The Model of Care Partner Engagement is introduced and described as an evidence-informed framework that nurses can use to guide the development of care partnerships.
Rethinking healthcare transitions and policies: Changing and expanding roles in transitional care
Every effort should be made to dismantle these internal barriers, standardize goals, and assess and customize navigation models to address the escalating cost of re-admissions and medical errors resulting from inadequate healthcare transitions.
Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial
A nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population.


Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial
Examination of the effectiveness of a transitional care intervention delivered by advanced practice nurses to elders hospitalized with heart failure to see if it improves the quality of life for these elders.