Transitional Care in the Patient-Centered Medical Home: Lessons in Adaptation.

Older adults with multiple chronic conditions (MCCs) typically have risk factors (e.g., functional deficits, social barriers) that complicate the management of their healthcare, often with devastating human and economic consequences. Finding new ways to provide patient-centered care to community-based older adults with MCCs is essential. Two current models of care, the Patient-Centered Medical Home (PCMH) and the Transitional Care Model (TCM), have demonstrated improvements in the outcomes of high-risk older adults at different points on the chronic illness trajectory. However, neither care management approach has optimally engaged vulnerable patients to address needs throughout both acute and more stable transitions in health. In this article, we summarize the development of the PCMH plus TCM (hereafter, PCMH + TCM), an innovative approach to care, and the experience of the providers involved in testing the feasibility of implementing the PCMH + TCM. Using content analyses to code open-ended survey responses from transitional care nurses and PCMH clinical leaders', two major themes, collaboration and communication, emerged as critical to the process of implementing the PCMH + TCM. Barriers and facilitators to implementing the PCMH + TCM are presented. Findings support that the TCM can be adapted and integrated into the PCMH with meticulous planning and implementation.

Transitions in Care from the Hospital to Home for Patients With Diabetes.

In Brief Diabetes is a common coexisting chronic condition among older adults that can complicate a hospitalization and transition back to the community. The Transitional Care Model, which offers a set of time-limited, hospital-to-home services coordinated by a master's-prepared advanced practice nurse, is one option that could improve outcomes for patients with diabetes. A descriptive case study is presented.

Case study: Transitional care for a patient with benign prostatic hyperplasia and recurrent urinary tract infections.

Chronic urologic conditions, including benign prostatic hyperplasia, recurrent urinary tract infections, and urinary incontinence, are common in older adults. This article highlights the urologic and transitional care needs of an elderly, cognitively impaired male during and after an acute hospitalization. Collaboration between the patient, his family, the advanced practice nurse, primary care providers, and outpatient urology office are described. The importance of mutual goal setting and a focused plan for transitional care are discussed.

Medication problems occurring at hospital discharge among older adults with heart failure.

Medication reconciliation problems are common among older adults at hospital discharge and lead to adverse events. The purpose of this study was to examine the rates and types of medication reconciliation problems among older adults hospitalized for acute episodes of heart failure who were discharged home. This secondary analysis of data generated from a transitional care intervention included 198 hospital discharge medical records, representing 162 patients. A retrospective chart review comparing medication lists between hospital discharge summaries and patient discharge instructions was completed to identify medication reconciliation problems. Most hospital discharges (71.2%) had at least one type of reconciliation problem and frequently involved a high-risk medication (76.6%). Discrepancies were the most common problem (58.9%), followed by incomplete discharge summaries (52.5%) and partial patient discharge instructions (48.9%). More attention needs to be given to the quality of discharge instructions, and the problem of vague phrases (e.g., "take as directed") can be addressed by adding it to "do not use" lists to promote safer transitions in care.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention.

PURPOSE: The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs). DESIGN AND METHODS: APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences. RESULTS: Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond. IMPLICATIONS: APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

Care coordination for cognitively impaired older adults and their caregivers.

Dementia and delirium, the most common causes of cognitive impairment (CI) among hospitalized older adults, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these older adults and their caregivers are particularly vulnerable to systems of care that either do not recognize or meet their needs. The consequences can be devastating for these older adults and add to the burden of hospital staff and caregivers, especially during the transition from hospital to home. Unfortunately, little evidence exists to guide optimal care of this patient group. Available research findings suggest that hospitalized cognitively impaired elders may benefit from interventions aimed at improving care management of both CI and co-morbid conditions but the exact nature and intensity of interventions needed are not known. This article will explore the need for improved transitional care for this vulnerable population and their caregivers.

Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure.

The aim of this study was to investigate whether, in a randomized controlled trial (RCT) of vulnerable elders with heart failure (HF), advanced practice nurses (APNs) who were coordinating care in the transition from hospital to home could improve outcomes, prevent rehospitalizations, and reduce costs when compared with usual care. The APN strategies focused on improving patient and family or caregiver effectiveness in managing their illnesses, strengthening the patient-provider relationship, and managing comorbid conditions while improving overall health. The results were positive. By capitalizing on the patient's desire to achieve their identified goals, APNs successfully educated patients about the meaning of their symptoms and appropriate self-management strategies; improved patient-provider communication patterns; and marshaled caregiver and community resources to maximize patient adherence to the treatment plan and overall quality of life. While HF was the primary reason for enrollment in the study, optimal health outcomes demanded a strong focus on integrating management of comorbid conditions and other long-standing health problems. Specific strategies used by the APN to achieve these positive outcomes are addressed in this report. These strategies are compared with nursing interventions used in other RCTs of HF home management. Directions for future research are explored.