This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
The problem with transitions
Older adults leaving the hospital often go home with new medications, unfamiliar instructions and several follow-up appointments, and many are readmitted within weeks. Care transitions are a weak point in health care delivery, because responsibility passes from one setting to another and information can be lost.
Two evidence-based models
Advanced practice nurse–centered discharge planning and home follow-up (Naylor et al., 1999). In a randomized trial at two hospitals in Philadelphia, 363 patients aged 65 or older at risk for poor outcomes after discharge received either usual care or a protocol delivered by advanced practice nurses: comprehensive discharge planning and home visits and telephone follow-up after discharge. By 24 weeks, 20.3% of intervention patients had been readmitted at least once, compared with 37.1% of controls. The intervention group had fewer multiple readmissions (6.2% vs. 14.5%) and fewer hospital days per patient (1.53 vs. 4.09), and total Medicare reimbursements were about half those of the control group ($0.6 million vs. $1.2 million). Functional status, depression and satisfaction didn't differ.
The Care Transitions Intervention (Coleman et al., 2006). In a randomized trial of 750 community-dwelling adults aged 65 or older in an integrated delivery system in Colorado, intervention patients received tools to support communication across care settings, encouragement to take a more active role in their care, and guidance from a "transition coach." Rehospitalization rates were lower at 30 days (8.3% vs. 11.9%) and 90 days (16.7% vs. 22.5%), and mean hospital costs at 180 days were lower ($2,058 vs. $2,546).
Comparing the models
| Feature | Naylor et al. (1999) | Coleman et al. (2006) |
|---|---|---|
| Who delivers it | Advanced practice nurses | A transition coach (an advanced practice nurse in the trial) |
| Focus | Clinical management and discharge planning | Coaching patients and caregivers to manage their own care |
| Intensity | Higher: home visits and calls over weeks | Lower: one home visit and follow-up calls |
| Main effect | Large reduction in readmissions over 24 weeks | Smaller reduction at 30 and 90 days |
| Best fit | Patients with complex needs and high risk | A broader group of older patients |
Recommendation for a health system
The illustrative health system in this paper has high 30-day readmission rates among older adults with heart failure and chronic lung disease. A tiered approach would match each model to the patients it suits best:
- Identify risk at admission with a validated readmission risk tool.
- High-risk patients receive APRN-led transitional care: discharge planning that begins on admission, a home visit within 48 hours, and weekly calls for 4 weeks.
- Moderate-risk patients receive transition coaching focused on a personal health record, medication self-management, recognizing warning signs and keeping follow-up appointments.
Measuring success
Outcomes include 30- and 90-day readmissions, emergency department visits, follow-up appointment completion within 7 days, patient-reported confidence in self-management and the program's cost compared with savings from avoided readmissions.
The MSN-prepared nurse's role
The MSN-prepared nurse leads the design, makes the business case to leaders using trial data, trains staff, builds referral pathways with community partners and monitors results.
References
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. https://doi.org/10.1001/archinte.166.17.1822
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613–620. https://doi.org/10.1001/jama.281.7.613
