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?
METHODS
Design:
randomised controlled trial.
Allocation:
{concealed}.*
Blinding:
blinded {data collectors}.*
Follow up period:
1 year after index hospital admission.
Setting:
6 academic and community hospitals in Philadelphia, Pennsylvania, USA.
Patients:
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.
Intervention:
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 …
