CLINICAL PRACTICE

Transitional Care Partners: A hospital-to-home support for older adults and their caregivers Cristina Hendrix, DNS, GNP-BC (Nurse Investigator)1,2,3 , Sara Tepfer, MSW, LCSW (Social Worker)1 , Sabrina Forest, DNP, ANP-BC (Nurse Practitioner)4 , Karen Ziegler, MSN, ANP-BC (Nurse Practitioner)4 , Valerie Fox, MS, OTR/L (Occupational Therapist)4 , Jeannette Stein, MD (Physician)4 , Eleanor S. McConnell, PhD, GCNS (Nurse Investigator)1,2,3 , Susan Nicole Hastings, MD (Physician)1,3,5,6 , Kenneth Schmader, MD (Physician)1,3,6 , & Cathleen Colon-Emeric, MD (Physician)1,3,6 1

Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina Duke University School of Nursing, Durham, North Carolina 3 Duke University Center for the Study of Aging and Human Development, Durham, North Carolina 4 Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina 5 Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina 6 Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina 2

Keywords Geriatric; nurse practitioners; home care; caregiver; veterans’ health; transitional care model. Correspondence Cristina Hendrix, DNS, GNP-BC, DUMC 3322, Durham, NC 27710. Tel: 919-684-9358; Fax: 919-681-8899; E-mail: Cristina.hendrix@ duke.edu, [email protected] Received: March 2011; accepted: August 2011 doi: 10.1111/j.1745-7599.2012.00803.x

Abstract Purpose: To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans. Data sources: Hospital records of TLC patients to track their hospital and emergency department visits before and after the TLC Partners enrollment. Caregivers of patients completed Preparedness in Caregiving and the Short Form Zarit Burden Scale during the first week of the TLC Partners enrollment and on the week when the services ended. Conclusions: The proportion of patients with one or more emergency department visits and rehospitalization is consistently lower among TLC patients compared to non-TLC patients at 30 and 60 days of hospital discharge. The mean preparedness and burden scores before and after the program essentially remained the same. Implications for practice: The description of the implementation of the TLC Partners offers an example of how nurse practitioner-led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models.

Although only about 13% of the population in the United States are aged 65 years and older (Federal Interagency Forum on Aging-Related Statistics, 2010), older adults comprise approximately 36% of hospital admissions and 50% of hospital expenditures in the country (Courtney et al., 2009; Parker, 2005). Many older adults are admitted to the hospital for an acute, potentially reversible condition from which recovery is expected. However, because of multiple comorbidities, complex medication regimens, and frailty, many older adults are discharged from the hospital with lingering ill-effects of their disease and treatment. In addition, their convalescence is often complicated by diminished functional status precipitated

or worsened by their hospitalization (Boltz, Capezuti, Shabbat, & Hall, 2010; Buurman, Parlevliet, van Deelen, de Haan, & de Rooij, 2010). Compounding the challenges of optimizing patients’ readiness for discharge is the emphasis on shorter hospital stays (Federal Interagency Forum on Aging-Related Statistics, 2010), which frequently lead to premature discharges. Consequently, many older adults and their caregivers experience complicated hospital-to-home transitions (Kripalani, Jackson, Schnipper, & Coleman, 2007). The hospital-to-home transitional period is replete with fragmented care. The lack of coordination and poor delineation of postdischarge responsibilities among

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healthcare providers place older patients and their caregivers at a high risk for postdischarge adverse events. For example, on discharge from the hospital, 30% of older patients have at least one medication discrepancy with the potential to cause harm (Kwan et al., 2007). About 35% of posthospitalization appointments for diagnostic testing are missed (Moore, McGinn, & Halm, 2007). Because of the high demands placed on informal caregivers to assist their loved ones at home, many caregivers are at high risk for depression, anxiety, feelings of burden, and decreased quality of life (Garlo, O’Leary, Van Ness, & Fried, 2010; Winter, Bouldin, & Andresen, 2010). One in five Medicare beneficiaries discharged from acute care hospitals is readmitted within 30 days; this readmission rate increases to about 33% within 90 days of discharge (Hasan et al., 2010; Hernandez et al., 2010; Minott, 2008; Ventura, Brown, Archibald, Goroski, & Brock, 2010). Evidence suggests that when older patients and their caregivers are supported during the hospital-to-home transitional period, adverse outcomes may be minimized. Frail older patients recently discharged from the hospital were less likely to report discharge problems when their primary care providers were aware of their recent hospitalization (Arora et al., 2010). In another study, Hernandez et al. (2010) reported that the risk of 30-day readmission was 15% lower among patients who had early follow-up after discharge than those who did not. The role of nurses, specifically advanced practice nurses, has also been associated with improved experience during the hospital-to-home transition. Naylor and Keating (2008) evaluated studies involving multidimensional models of transitional care to address problems that commonly occur after patients are discharged home from the hospital. They found that nurse-led interdisciplinary interventions have consistently improved quality of transitional care and decreased resource utilization. However, such interventions have not been disseminated widely, nor have they been evaluated within a population with a higher burden of chronic illness, such as the Veterans Affairs (VA) Health System. This article describes the Transitional Care (TLC) Partners Program at the Durham VA Medical Center, Durham North Carolina with the aims of (a) establishing the generalizability of nurse-led transitional care programs to VA patients with high burden of chronic illnesses and social challenges and (b) describing the adaptation and implementation of evidence-based transitional care programs to a unique system that may inform other providers and administrators wishing to offer such services. Preliminary results associated with the program are presented and plans for optimization of the TLC Partners’ structure and process are discussed. Because this was a clinical demonstration project, the Institutional Review Board (IRB) of 408

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the Durham VA determined that IRB approval was not needed.

TLC Partners: A clinical demonstration program The TLC Partners Program was developed in response to a request for proposals from the Veterans Health Administration (VHA), Office of Geriatrics and Extended Care to field-test innovative alternatives to institutional extended care for veterans. The VHA is committed to transforming its healthcare organization to embody patient-centered care that includes alternative services to prevent institutional extended care for veterans. Specific care models of interest include evidence-based programs designed to reduce postacute care in institutionalized settings, including rehospitalizations. The Durham Veterans Affairs Medical Center (VAMC) is a tertiary hospital facility that serves about 53,000 unique veterans living in a 26-county area of central and eastern North Carolina. In 2008, the Durham VAMC had a total of 6841 inpatient admissions and about 37% of these veterans were aged 65 and above. Stakeholder groups including inpatient providers, primary care providers, and case managers at the Durham VAMC agreed on a need for prompt follow-up at home to support the transition of high-risk patients following hospital discharge. The Durham VAMC has a well-established Home-Based Primary Care program; however, as a result of resource limitations, many patients referred to this service have to be waitlisted before they are seen. The literature shows fewer hospitalizations and admissions to nursing homes if the patient receives home care visits (Wajnberg, Wang, Aniff, & Kunins, 2010) The pressing need to support the hospital-to-home transitional period of high-risk patients served as the driving force in establishing the TLC Partners.

Naylor’s Transitional Care Model as a framework for the TLC Partners Program The TLC Partners is based on Naylor’s Transitional Care Model (Naylor et al., 2004). This model provides a framework for planning and organizing a structure to provide comprehensive in-hospital planning and home followup for chronically ill high-risk older adults in order to streamline plans of care and prevent decline of health status. While interdisciplinary in nature, the Transitional Care Model is nurse-led and has demonstrated positive patient outcomes such as reduced rehospitalization and emergency department visits after hospital discharge (Naylor et al., 1999, 2004, 2009). To the authors’ knowledge, the Transitional Care Model has not been used as

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Table 1 TLC Partners implementation timeline Year 1

Program development Meet with facility leaders, inpatient providers Hire/train TLC Team Prepare logistics Prepare materials/protocols Program execution Implement screening alert Begin hospital and home visits Program evaluation Prepare and write reports Collect and analyze outcomes Disseminate program

Year 2

Second quarter

Third quarter

Fourth quarter

First quarter

Second quarter

Third quarter

Fourth quarter

X

X

X

X

X

X

X

X X X

X X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X X

X X

X

X

X

X refers to when the activities listed on the first column were done.

a framework to provide transitional care services to older veterans in VAMC settings. Consistent with the Transitional Care Model, the TLC Partners is led by a nurse practitioner (NP) and provides posthospital medical care to patients on a time-limited period. However, a unique feature of the TLC Partners is the addition of an occupational therapist (OT) and a social worker (SW) as integral team members in order to provide expanded access to additional services to TLC patients. This is particularly important as older veterans are likely to be more medically and socioeconomically vulnerable than the general population (Abbott, Stoller, & Rose, 2007; Agha, Lofgren, VanRuiswyk, & Layde, 2000; Corser, 2006). For those patients with an identified caregiver involved in patient care, the TLC Partners provides health education and training of skills. Therefore, in addition to reducing the rate of rehospitalization and emergency department visits of patients after their hospital discharge, the TLC Partners also aims to reduce caregiving burden and improve preparedness in caregiving.

Patient eligibility and program description The target patient population is hospitalized veterans aged 60 years or above, who live within 35 miles from the Durham VAMC, will be discharged home, are not enrolled in hospice, and will benefit from having close medical surveillance after hospital discharge. Patient referrals

primarily come from inpatient providers responsible for discharge planning, such as nurse case managers, SWs, and inpatient physicians. Once a consult is received by the TLC Partners and the patient is deemed eligible for the program, a TLC NP conducts a hospital visit before the patient’s discharge to initiate the relationship with the patient and begin planning for home care. During that time, the TLC NP also assesses the need for home visits by the TLC SW and TLC OT. For patients who are ineligible to participate in the program, educational materials for caregivers and information on community-based resources are provided. Recommendations for other support such as Telehealth services and home health are communicated by the TLC NP to the patient’s inpatient providers. The TLC NP conducts a home visit within 2–3 days of discharge; if needed, the TLC OT and/or TLC SW conduct separate visits within 5 days of discharge. Additional home visits are determined based on the patient’s clinical progress and caregiver needs. The TLC team uses the latest evidence-based guidelines for common medical and geriatric syndromes to promote highquality care provided for approximately 30 days following hospital discharge. Upon discharge from the program, a discharge summary consisting of progress report, patient’s list of medications, and recommendations for care is provided to the patient’s primary care provider. Additionally, patients are referred to other services within 409

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the VA when indicated, such as Home-Based Primary Care, community-based adult day healthcare programs, and other VA community programs.

Implementation of the TLC Partners Table 1 provides an overview of the implementation timeline. After receiving notification of successful funding decision, several meetings were held with facility leaders for their input and support in launching the TLC Partners. Plans for obtaining resources were discussed and timeline for program implementation was set. Additionally, commitment to participate in future quarterly meetings from facility leaders was obtained as this was seen as key component for program sustainability. Other activities that were prioritized accounted for the unique features within the VA. These activities included posting of job positions for TLC providers and staff, dissemination of program information, development of an alert mechanism to identify hospitalized patients at high risk for rehospitalization, development of template for electronic medical record documentation, and finalizing TLC office locations and program logistics. Hiring of licensed providers at the VA often takes considerable time because of the steps involved before a formal offer can be extended. The VA boasts of a sophisticated electronic medical record that can be of use to systematically identify patients with risk factors for rehospitalization. Lastly, the Durham VAMC is a teaching facility and there are frequent rotations among inpatient physicians. Therefore, it was paramount that program information was disseminated on a frequent basis so that knowledge about the program among providers is sustained. The TLC Partners received its first patient consult almost 8 months after beginning program development activities In the first month of accepting consults, 11 (48%) of the 23 patients referred did not meet program eligibility criteria, primarily because of patients being too young or living outside of the 35-mile radius. Monthly meetings with the inpatient physicians and nurse case managers were then set up by the TLC NP to review program eligibility on a frequent a basis. A brochure that summarizes program information was also circulated during the early phase of the program. To ensure that all TLC referrals were processed similarly and completely, the TLC staff developed an operational algorithm of receiving consults; determining eligibility of patients; and planning as well as providing for TLC care. The TLC Medical Support Assistant acted as the gatekeeper of the TLC Partners program and maintained the database to track program-related outcomes. 410

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Program data collection As a clinical demonstration project, the TLC Partners tracks hospital and ED visits of TLC patients up to 90 days following their hospital discharge. For comparison, the same tracking is performed for those patients who were referred to the TLC but were not enrolled. For an additional comparison, a previous Durham VAMC hospitalization, no sooner than 90 days of hospital admission that led to the TLC Partners consult, was identified for each TLC patient (when applicable). This is called pre-TLC hospitalization. Rehospitalization and ED visits related to this pre-TLC hospitalization were identified through a review of their Durham VAMC records. To track caregiver outcomes, caregivers of TLC patients completed the Preparedness in Caregiving (Archbold, Stewart, Greenlick, & Harvath, 1990) and Short Zarit Burden Scale (Bedard et al., 2001). These scales were administered during the first week of the TLC Partners enrollment and on the week when the TLC Partners services ended.

Program preliminary outcomes The TLC Partners team conducted analyses on preliminary data as part of its formative evaluation plan. In the first 5 months of program implementation, the TLC Partners received a total of 80 consults. Of these, 54 (67.5%) veterans met criteria for enrollment and were enrolled in the TLC Partners, whereas 26 (32.5%) were ineligible to participate because the patients were discharged to a facility (n = 8); lived outside of the 35-mile radius (n = 7); were too young (n = 2); were already discharged from the hospital before the TLC NP can do a hospital visit (n = 6); or patient’s condition was too sick (n = 3). An additional seven patients were removed from the program after their enrollment but before their first home visit because home visitations were refused (n = 5) or the patient died (n = 2). Table 2 summarizes the characteristics of the 47 patients who have been enrolled and followed by the TLC Partners. Almost all patients were male and the majority was at least 75 years of age. A review of these patients’ medical records encompassing 3 months prior to their hospitalization that led to the TLC referral revealed that more than half of them had at least one ED visit and about 45% had been admitted at least once to the Durham VAMC. Most of the patients referred to the TLC Partners stated that they have a caregiver at home. The proportion of patients with rehospitalization and ED visits following hospital discharge was calculated in order to determine the impact of the TLC Partners program following hospital discharge. Two comparison

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Table 2 Characteristics of patients enrolled and followed by the TLC Partners (N = 47) Gender Male Female

Discharge diagnoses Genitourinary including renal Cardiovascular Gastrointestinal Neurological Pulmonary Others Number of veterans with ED visits 3 months before TLC consultb No ED visit 1 ED visit 2 ED visits 3 or more ED visits a b

Race White African American Others

45 (96%) 2 (4%)

Age 60–64 65–74 75–84 85 and older

22 (47%) 18 (38%) 7 (15%)

8 (17%) 10 (21%) 16 (34%) 13 (28%)

Veterans with caregivers at home Yes 33 (70%) No 14 (30%)

11 (23%) 9 (19%) 6 (13%) 6 (13%) 6 (13%) 9 (19%)

Number of veterans with hospitalizations before TLC consulta 0 hospitalizations 26 (55%) 1 hospitalizations 14 (30%) 2 hospitalizations 4 (9%) 3 hospitalizations 3 (6%)

22 (47%) 14 (30%) 2 (4%) 9 (19%)

Does not include the hospitalization that led to the TLC referral. Does not include the ED visits that led to the TLC referral.

Table 3 Proportion of patients with ED visitsa and rehospitalization be-

Table 4 Proportion of patients with ED visitsa and rehospitalizations

tween TLC and non-TLC patients

before TLC and with TLC hospitalizations (N = 24)

Proportion of patients with ED visits after hospitalization

TLC patients (N = 30) Non-TLC patients (N = 11) a

Proportion of patients with readmission after hospitalization

30 days

60 days

30 days

60 days

20% 27%

27% 36%

23% 36%

23% 64%

ED visits that did not result in a hospital admission.

analyses were used. First, the proportion of patients with one or more rehospitalization and ED visits after hospital discharge was compared between those who were followed by the TLC Partners (TLC patients) and those who were referred but not enrolled in the TLC (non-TLC patients). For this comparison, we included all TLC patients (N = 30) and non-TLC patients (N = 11) who have data up to 60 days of hospital discharge when the formative evaluation was conducted. As a result of the low sample size and preliminary nature of these data, no statistical tests were performed at this time. As seen in Table 3, the proportion of patients with one or more ED visits and rehospitalization is consistently lower among TLC patients compared to non-TLC patients at 30 days and 60 days of hospital discharge. When the total number of ED visits and hospitalizations made by patients in each group at 30 and 60 days were totaled and averaged based on the number of patients, the TLC patients had lower number

Proportion of patients with ED visits after hospitalization

Before TLC hospitalization Hospitalization with TLC a

Proportion of patients with readmission after hospitalization

30 days

60 days

30 days

60 days

29% 17%

42% 25%

4% 17%

21% 17%

ED visits that did not result in a hospital admission.

of ED visits and rehospitalizations on both 30 and 60 days following hospital discharge. The second method of analysis compared rehospitalizations and ED visits on enrolled patients after a previous hospitalization (pre-TLC hospitalization) and following the hospitalization during which they were enrolled in the program. Of the 30 TLC patients used in the preceding analysis, 24 had previous hospitalizations at the Durham VAMC before the TLC referral. The interval between the pre-TLC hospitalization and TLC hospitalization varied widely, from 6 years to a few months. The proportion of patients who were rehospitalized and the proportion of patients with ED visits associated with preTLC hospitalization were compared to the proportion associated with TLC hospitalization (Table 4). The proportion of patients who were rehospitalized and who had ED visits is consistently lower with TLC hospitalization 411

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compared to pre-TLC hospitalization except at 30 days after hospital discharge.

Caregiver outcomes At the time that the formative evaluation was conducted, 14 caregivers of patients completed the Preparedness in Caregiving (Archbold et al., 1990) whereas 15 caregivers completed the Zarit Burden Scale (Bedard et al., 2001). Of these, six (43%) caregivers had an increase in their total preparedness scores. The mean preparedness scores before and after TLC were 263 and 264, respectively. For caregiving burden, eight (53%) had a decrease in caregiving burden at the end of the TLC as reflected by their burden scores. The mean burden score before and after the TLC was the same at 5.5.

Narrative feedback from TLC Partners patients and caregivers In addition to the preliminary outcomes discussed above, feedback from TLC patients and their caregivers were solicited to obtain information that can be used for program improvement. Overall, both patients and caregivers provided overwhelmingly positive feedback. Two themes emerged from these anecdotes—patients and caregivers found it reassuring to have ready access to someone who can help when issues or problems arise, and the benefit of not having to drive back and forth to the VA for care. Responses that are representative of the feedback received are provided below: . . . It’s security to know that you can call someone if you have an issue or problem and get help. It saves a lot of time not having to drive back and forth to the VA.” “You are a really good connection from home to the physician. . . . You don’t know how much it means to have someone calling you to check on you and letting me know what is going on . . .

Discussion Through the successful implementation of the TLC Partners, the generalizability of nurse-led transitional care programs, such as the Transitional Care Model, in VAMC settings is supported. To date, evidence abound that hospital-to-home transitional care interventions promote positive outcomes among patients with congestive heart failure (Naylor et al., 2004) and vulnerable elders (Naylor et al., 2009). TLC Partner’s preliminary outcomes demonstrate that older veterans who are likely to be more medically vulnerable than the general population (Abbott et al., 2007; Agha et al., 2000; Corser, 2006) may also benefit from transitional care services. The development of the TLC Partners has been positive and well412

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received by inpatient clinicians as well as patients and caregivers at the Durham VAMC. All inpatient providers at the facility recognize the many needs that older patients have after their discharge from the hospital (Kripalani et al., 2007) and are eager to refer patients to the TLC Partners. Continued future regular in-service sessions on program eligibility to inpatient providers are required to maximize the number of eligible patients referred to the TLC Partners. Although this is challenging in teaching hospitals with frequent rotations of providers such as the Durham VAMC, it is important so that the TLC Partners resources can be optimized to those who are eligible to participate, and prompt identification of other support services can be performed for those found ineligible. The emphasis on shorter hospital stays (Federal Interagency Forum on Aging-Related Statistics, 2010) creates challenges for the TLC NP to make a hospital visit before the patients are discharged from the hospital. In the first 5 months of program implementation, the TLC NP was not able to conduct a hospital visit on six patients who would have otherwise been admitted into the program. Conducting a hospital visit by the TLC NP, however, is important as the face-to-face encounter between the patient and the TLC NP contributes to the establishment of the patient–provider relationship. More importantly, the hospital visit allows the TLC NP to assess the priority needs of patients once discharged home. Therefore, regular reminder to inpatient providers to refer patients early into the program needs to continue. Many older veterans referred to the TLC Partners are frail with substantial medical problems as evidenced by a number of ED visits and hospitalizations leading into their TLC Partners referral. Because, in general, older veterans have limited sources of healthcare assistance than older nonveterans (Agha et al., 2000; Corser, 2006) the importance of the TLC Partners to support the hospitalto-home transitional services cannot be overstated. To date, program preliminary outcomes suggest that the TLC Partners may be able to reduce ED visits of older veterans after their hospital discharge. These reductions were seen consistently in both types of analyses that were conducted. Rehospitalizations may also be reduced with TLC care as found when patients with TLC and without TLC were compared. However, when rehospitalizations before TLC and with TLC were compared on 24 patients who have had previous hospitalizations at the Durham VAMC, the number of rehospitalizations was found to be higher on hospitalizations associated with TLC. However, some before TLC hospitalizations used in the comparison may have happened several years ago, when patients were younger and healthier, and therefore this comparison may underestimate the utility of the program.

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Relying merely on the rate rehospitalization and ED visits after hospital discharge may not be the most sensitive way to measure programmatic success especially when dealing with very sick and frail older patients. Other outcomes may need to be identified to support sustainability of the program. Formal economic analyses need to be completed, and may be especially useful in a closed system such as the VA where the incentives to reduce rehospitalization and ED use are aligned among all settings of care. In the early evaluation of caregiver outcomes, there was no consistent improvement observed in caregiver burden and caregiving preparedness. Although caution should be observed in interpreting these results because of small sample size, one thought may be that mere training and education about patient care may not be enough to produce an effect in caregiving. Rather, caregivers may need actual physical assistance in the form of nurse aid time, respite care, or financial support to support their caregiving role. One limitation of the TLC Partners is that it relies on Durham VAMC records alone to monitor hospitalizations and ED visits. This approach does not capture the use of acute care services in other settings, which may minimize programmatic outcomes. However, because all enrolled patients lived within a close radius of the hospital, this is not likely to have a major impact. Small numbers of patients were included in this preliminary analysis, so statistical calculations were not performed. However, statistical analysis is planned after at least 150 patients are enrolled to allow adequate power to detect a meaningful difference.

Summary and implications for nursing practice The description of the implementation of the TLC Partners program offers an example of how nurse-led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models. This clinical demonstration showcases context-specific modifications that were needed to implement a transitional care model in a VA medical center, how strategies such as regular meetings with hospital staff can be used to facilitate implementation fidelity, and how outcomes can be monitored to ensure that expected improvements in transitional care are realized.

Acknowledgments The TLC Partners is a clinical demonstration program that received funding from the Veterans Health Affairs,

Office of the Geriatrics and Extended Care as part of its Transformation-21 Initiative.

References Abbott, K. H., Stoller, E. P., & Rose, J. H. (2007). The structure and function of frail male veterans’ informal networks. Journal of Aging Health, 19(5), 757–777. Agha, Z., Lofgren, R. P., VanRuiswyk, J. V., & Layde, P. M. (2000). Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine, 160(21), 3252–3257. Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. (1990). Mutuality and preparedness as predictors of caregiver role strain. Research in Nursing and Health, 13(6), 375–384. doi:10.1002/nur.4770130605 Arora, V. M., Prochaska, M. L., Farnan, J. M., D’Arcy, M. J. 5th, Schwanz, K. J., Vinci, L. M., . . . Johnson, J. K. (2010). Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: A mixed method study. Journal of Hospital Medicine, 5(7), 385–391. Bedard, M., Molloy, D. W., Squire, L., Dubois, S., Lever, J. A., & O’Donnell, M. (2001). The Zarit Burden Interview: A new short version and screening version. Gerontologist, 41(5), 652–657. doi:10.1093/geront/41.5.652 Boltz, M., Capezuti, E., Shabbat, N., & Hall, K. (2010). Going home better not worse: Older adults’ views on physical function during hospitalization. International Journal of Nursing Practice, 16(4), 381–388. doi:10.1111/j.1440-172X.2010.01855.x Buurman, B. M., Parlevliet, J. L., van Deelen, B. A., De Haan, R. J., & De Rooij, S. E. (2010). A randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge: The Transitional Care Bridge. BMC Health Services Research, 10, 296, 1–9. doi:10.1186/1472-6963-10-296 Corser, W. D. (2006). The perceptions of older veterans concerning their postdischarge outcome experiences. Applied Nursing Research, 19(2), 63–69. doi:10.1016/j.apnr.2005.05.004 Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57(3), 395–402. doi:10.1111/j.1532-5415.2009.02138.x Federal Interagency Forum on Aging-Related Statistics. (2010). Older Americans 2010: Key indicators of well-being. Washington, DC: US Government Printing Office. Garlo, K., O’Leary, J. R., Van Ness, P. H., & Fried, T. R. (2010). Burden in caregivers of older adults with advanced illness. Journal of the American Geriatrics Society, 58(12), 2315–2322. doi:10.1111/j.1532-5415.2010. 03177.x Hasan, O., Meltzer, D. O., Shaykevich, S. A., Bell, C. M., Kaboli, P. J., Auerbach, A. D., . . . Schnipper, J. L. (2010). Hospital readmission in general medicine patients: A prediction model. Journal of General Internal Medicine, 25(3), 211–219. doi:10.1007/s11606-009-1196-1 Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., . . . Curtis, L. H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. Journal of the American Medical Association, 303(17), 1716–1722. doi:10.1001/jama.2010.533 Kripalani, S., Jackson, A., Schnipper, J. L., & Coleman, E. (2007). Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2(5), 314–323. doi:10.1002/ jhm.228 Kwan, Y., Fernandes, O. A., Nagge, J. J., Wong, G. G., Huh, J. H., Hurn, D. A., . . . Bajcar, J. M. (2007). Pharmacist medication assessments in a surgical preadmission clinic. Archives of Internal Medicine, 167(10), 1034–1040. doi:10.1001/archinte.167.10.1034

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Minott, J. (2008). Reducing hospital readmissions. Retrieved from http://www. academyhealth.org/files/publications/Reducing Hospital Readmissions.pdf Moore, C., McGinn, T., & Halm, E. (2007). Tying up loose ends: Discharging patients with unresolved medical issues. Archives of Internal Medicine, 167(12), 1305–1311. doi:10.1001/archinte.167.12.1305 Naylor, M., & Keating, S. A. (2008). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108(9 Suppl.), 58–63; quiz 63. doi:10.1097/01.NAJ.0000336420.34946.3a 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. Journal of Hospital Medicine, 281(7), 613–620. doi:10.1001/jama.281.7.613 Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675–684. doi:10.1111/j.1532-5415.2004.52202.x Naylor, M. D., Feldman, P. H., Keating, S., Koren, M. J., Kurtzman, E. T., Maccoy, M. C., & Krakauer, R. (2009). Translating research into practice:

414

C. Hendrix et al.

Transitional care for older adults. Journal of Evaluation in Clinical Practice, 15(6), 1164–1170. doi:10.1111/j.1365-2753.2009.01308.x Parker, S. (2005). Do current discharge arrangements from inpatient hospital care for the elderly reduce readmission rates, the length of inpatient stay or mortality, or improve health status? Copenhagen, WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/Document/ E87542.pdf Ventura, T., Brown, D., Archibald, T., Goroski, A., & Brock, J. (2010). Improving care transitions and reducing hospital readmissions: Establishing the evidence for community-based implementation strategies through the care transitions theme. Remington Report, 18, 24–30. Wajnberg, A., Wang, K. H., Aniff, M, & Kunins H. V. (2010). Hospitalizations and skilled nursing facility admissions before and after implementation of a home-based primary care program. Journal of the American Geriatrics Society, 58, 1144–1147. Winter, K. H., Bouldin, E. D., & Andresen, E. M. (2010). Lack of choice in caregiving decision and caregiver risk of stress, North Carolina, 2005. Preventing Chronic Disease, 7(2), 1–11.

Transitional Care Partners: a hospital-to-home support for older adults and their caregivers.

To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that su...
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