A decade of transitional care research with vulnerable elders

Area of Science:

• Gerontology
• Nursing Science
• Health Services Research

Background:

• Hospitalized elders with chronic cardiovascular illness face poor postdischarge outcomes.
• Transitional care models aim to bridge the gap between hospital and home care.
• Multidisciplinary teams are crucial for effective elder care management.

Purpose of the Study:

• To describe knowledge and clinical practice advancements from testing a transitional care model (TCM) over a decade.
• To improve postdischarge outcomes for older adults with chronic cardiovascular conditions.
• To identify patient and caregiver factors influencing TCM effectiveness.

Main Methods:

• Longitudinal testing and refinement of a transitional care model.
• Multidisciplinary research team collaboration.
• Analysis of patient and caregiver outcomes posthospitalization.

Main Results:

• The TCM demonstrated positive outcomes for elders and reduced healthcare costs.
• Identified specific patient profiles at risk for adverse outcomes.
• Elucidated predictors of caregiver burden and unique elder needs.
• Highlighted the role of advanced practice nurses in care transitions.

Conclusions:

• The refined TCM effectively improves outcomes for hospitalized elders with cardiovascular conditions.
• Findings advance understanding of patient, caregiver, and nursing roles in transitional care.
• The model offers a cost-effective approach to managing chronic illness in older adults.