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

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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?


Embedded ImageDesign:

randomised controlled trial.

Embedded ImageAllocation:


Embedded ImageBlinding:

blinded {data collectors}.*

Embedded ImageFollow up period:

1 year after index hospital admission.

Embedded ImageSetting:

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

Embedded ImagePatients:

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.

Embedded ImageIntervention:

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 …

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  • * Information provided by author.

  • For correspondence: Dr M D Naylor, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.

  • Source of funding: National Institutes of Health.