Back to Annual Meeting

Back to Annual Meeting

APHA Scientific Session and Event Listing

Mary D. Naylor, PhD, FAAN, RN, School of Nursing, University of Pennsylvania, Room 364 NEB, 420 Guardian Drive, Philadelphia, PA 19104, 215 898-6088, naylor@nursing.upenn.edu

A growing body of science suggests that older adults coping with multiple chronic conditions and complex therapies are particularly vulnerable to breakdowns in care. Since 1989, a multidisciplinary team of researchers based at the University of Pennsylvania has been testing and refining an innovative model of care coordination delivered by advanced practice nurses (APNs) for older adults making the transition from hospital to home. Findings from the team's three completed National Institute of Nursing Research (NINR) funded randomized clinical trials (RCTs) have consistently demonstrated the ability of this care model to improve quality and substantially decrease health care costs among high risk cognitively intact elders. An on-going clinical trial funded by the National Institute of Aging is testing the effects of the transitional care model among hospitalized elders who are cognitively impaired. Despite consistent positive outcomes, this research-based approach to care has not been integrated into clinical practice. With the support of The Commonwealth Fund and Jacob and Valeria Foundation, the Penn research team has formed a partnership with a major insurer in an effort to translate this approach to care for use in the “real world” of clinical practice and to promote its widespread adoption. This presentation will describe the Penn team's efforts to advance the science related to transitional care as well as to enhance the coordination of care and outcomes of a growing population of high risk chronically ill older adults.

Learning Objectives:

• Discuss the main aspects of cost effective transitional care
• Identify areas where transitional care is being implemented in practice.

Keywords: Access and Services,

Presenting author's disclosure statement:

Not Answered