A decade of transitional care research with vulnerable elders

This article describes the contributions to knowledge development and clinical practice during the past decade resulting from testing and refining a transitional care model with hospitalized elders by a multidisciplinary research team. A major goal of this research program has been to improve the postdischarge outcomes of older adults admitted to hospitals for an acute exacerbation of a chronic cardiovascular illness. In addition to demonstrating positive outcomes for elders while reducing costs, findings from the testing of the transitional care model have advanced knowledge of important patient and caregiver issues including the effects of the model of elders with medical versus surgical conditions, the profile of elders at risk for poor outcomes, predictors of caregiver burden, the unique needs of elders and the contributions of advanced practice nurses in meeting these needs, and decision making regarding home care referrals.