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 …

No Related Web Pages

Free Sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of EBN.
View free sample issue >>

EBN Journal Chat

The EBN Journal Chat offers readers the opportunity to participate in discussion about research articles and commentaries from Evidence Based Nursing (EBN).

How to participate >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.

Navigate This Article