RESUMO
ABSTRACT: One out of five Medicare beneficiaries is readmitted within 30 days after hospital discharge, and as many as three in four readmissions are preventable. This study describes transitional care interventions (TCIs) delivered by one faith community nurse (FCN) to at-risk seniors living in a certain ZIP code. Two years of nursing documentation (2,280 interventions) were translated into Nursing Interventions Classification standardized nursing language. Results indicate the FCN provided priority TCIs including spiritual care. In fully describing TCIs using a nursing language, results support that the FCN transitional care model is a method worth exploring to provide wholistic transitional care.
Assuntos
Enfermagem Paroquial , Terminologia Padronizada em Enfermagem , Cuidado Transicional , Idoso , Humanos , Estados Unidos , Medicare , Alta do PacienteRESUMO
The Medicare mandatory readmission reduction program has hospitals scrambling to reduce 30-day readmissions. A Faith Community Nurse (FCN) Transitional Care Model was developed from systematic literature review of predictive factors of readmission and pre- and postdischarge interventions that decrease readmission. The model presents specific FCN care that occurs pre- and posthospital discharge to support the patient in transitioning from one level of care to another, move toward wholistic health, and avoid unnecessary readmission.
Assuntos
Cristianismo , Medicare/normas , Enfermagem Paroquial/normas , Alta do Paciente/normas , Readmissão do Paciente/normas , Guias de Prática Clínica como Assunto , Cuidado Transicional/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Educação Continuada em Enfermagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Enfermagem , Inovação Organizacional , Estados UnidosRESUMO
OBJECTIVE: To conduct a cancer education intervention with racially diverse communities in South Carolina. METHODS: The study was conducted at eight different sites in six counties in SC. The intervention included a 3-h general cancer knowledge and 30-min prostate cancer knowledge component. Pre- and post-intervention surveys were administered. Maximum scores were 31, 10 and 5 for the general cancer knowledge, prostate cancer knowledge and perceived self-efficacy in patient-physician interaction instruments, respectively. Analyses were completed using SPSS 16.0, SAS 9.1.3, and R v2.6.1. RESULTS: The study sample consisted of 164 predominantly African American participants. Most of the participants who reported age were 50+ years (62.5%). Among those who reported income, 46.1% had an annual household income <$40,000. The mean general cancer knowledge pre-test score was 26.2 (standard deviation (SD) 3.7) with a mean post-intervention increase of 2.15 points (p<0.01). The mean pre-test prostate cancer knowledge score was 7.3 (SD 2.0) with a post-intervention increase of 0.48 points (p<0.01). Perceived self-efficacy in patient-physician interaction scores had a ceiling effect. CONCLUSION: General cancer knowledge and prostate cancer knowledge scores increased following the intervention. PRACTICE IMPLICATIONS: The intervention was successful in the short-term. It could be continued by community members.
