Evid Based Nurs 7:116 doi:10.1136/ebn.7.4.116
  • Treatment

Advanced practice nurse directed transitional care reduced readmission or death in elderly patients admitted to hospital with heart failure

 Q In elderly patients admitted to hospital with heart failure (HF), does a 3 month, comprehensive, transitional care intervention reduce readmissions and improve quality of life and functioning?



randomised controlled trial.




blinded {data collectors}.*

GraphicFollow up period:

1 year after index hospital admission.


6 academic and community hospitals in Philadelphia, Pennsylvania, USA.


239 English speaking patients ⩾65 years of age (mean age 76 y, 57% women) who were admitted to hospital from home with HF, alert and oriented, reachable by telephone, and residing ⩽60 miles from the admitting hospital. Exclusion criterion was end stage renal disease.


advanced practice nurse (APN) transitional care (TC) (n = 118) or usual care (n = 121). APN TC comprised (1) APN training by a multidisciplinary team; (2) Quality-Cost Model of APN Transitional Care management strategies (identification of patient and caregiver goals, individualised care plans, educational and behavioural strategies, coordination and continuity of …

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