Making Transitional Care More Effective & Efficient

Making Transitional Care More Effective & Efficient

APRNs Ensure Smooth Transition From Hospital to Home, Cutting Re-Hospitalization Rates for Geriatric Patients

Background & Goal

High rates of poor post-discharge outcomes put elderly patients back in the hospital soon after their release following treatment and up to one-third of those hospitalizations are considered preventable.

To focus on transitional care lead by master’s-prepared advanced practice nurses (APRNs) in conjunction with the patient’s entire health care team, targeting high-risk patients at risk for poor post-discharge outcomes in order to improve post-discharge outcomes. This lowers the rates of rehospitalization and thereby reducing health care costs.

Model Description

It is an evidence-based innovative model of hospital-to-home care in which APRNs work to ensure a smooth transition from hospital care to home care. The program assures that APRNs: establish a relationship with patients and their families soon after hospital admission; design the discharge plan in collaboration with the patient, the patient’s physician, other involved providers and their family caregivers; and implement the plan in the patient’s home following discharge, substituting for traditional skilled nursing follow-up. This reduces the incidence of poor communication among providers and health care agencies, inadequate patient and caregiver education and poor quality of care as well as enhances access to quality care.

Evidence of Success

  • Since 1991, when compared to standard care, the TCM has demonstrated longer intervals before initial re-hospitalizations, fewer re-hospitalizations overall, shorter hospital stays and better patient satisfaction.
  • A four-year trial (1997-2001) with a group of elderly patients hospitalized with heart failure, the APN Care Model cut hospitalization costs by more than $500,000, compared with a group receiving standard care – for an average savings of approximately $5,000 per Medicare patient.
  • Demonstrated efficacy in translating the evidence based innovation into practice, in partnership with a major insurer (Aetna, Inc.) targeting their Medicare Advantage consumers (2005-2007). The program was offered as an ongoing benefit for their high-risk members experiencing transitions from acute care to home in a select market (2011).
  • An ongoing clinical trial (2005-present) with hospitalized, cognitively impaired older adults and their family caregivers reveal similar health resource utilization outcomes as prior studies; health, quality of life and cost analyses ongoing.

    For More Information Contact:

    Mary D. Naylor, PhD, RN, FAAN

    Marian S. Ware Professor in Gerontology
    Director, NewCourtland Center for Transitions and Health
    University of Pennsylvania, School of Nursing
    Ralston Penn Center
    3615 Chestnut Street, RM 320
    Philadelphia, PA 19104-2676