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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.
Worldviews on Evidence-Based Nursing
|January 11, 2017
Summary
Effective nurse-led care transitions for older adults involve patient education, clear communication, standardized tools, optimized nursing roles, and strong organizational support. These elements are crucial for high-quality care transitions.
Area of Science:
- Gerontology
- Nursing Science
- Healthcare Management
Background:
- Nursing is vital for managing care transitions in complex older adults.
- Lack of consensus exists on effective nurse-led interventions for high-quality care transitions.
- A structured expert panel aimed to identify key components of these interventions.
Purpose of the Study:
- To identify and rank effective components of nurse-led care transition interventions for complex older adults.
- To establish consensus on essential elements for successful care transitions.
Main Methods:
- A modified Delphi consensus technique using the RAND method was applied.
- Twenty-three expert panelists rated statements derived from a literature synthesis.
- Consensus was reached through iterative rating, revision, and face-to-face meetings.
Main Results:
- Top components include patient/caregiver self-management education and coaching.
- Ensuring awareness of follow-up appointments and discharge plans is critical.
- Standardized documentation, comprehensive communication, optimized nursing roles, and strong organizational leadership are key.
Conclusions:
- Optimizing nurses' roles, including "warm hand-offs" and serving as a "go-to person," is essential.
- Challenges exist in optimizing nursing roles across care transition points.
- Further research is needed to identify effective nurse-led intervention components and their contextual effectiveness.
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