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Identifying Effective Nurse-Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured
Lianne Jeffs1, Kerry Kuluski2, Madelyn Law3
1St. Michael's Hospital Volunteer Association Chair in Nursing Research Scientist, Keenan Research Centre of the Li Ka Shing Knowledge Institute St. Michael's Hospital, Associate Professor, Lawrence S. Bloomberg Faculty of Nursing and Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Background:
Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions.
Methods:
A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements.
Results:
The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses' roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population.
Linking Evidence To Action:
Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.
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