Transitional
Care
Mary
D. Naylor, PhD, FAAN, RN
In
a series of three National Institute of Nursing Research-funded
randomized clinical trials, Dr.
Mary D. Naylor and her research team have
modified, tested, and refined a model of transitional
care delivered by master's prepared advanced practice
nurses (APNs) in conjunction with physician back-up
to elderly patients at high risk for poor post-discharge
outcomes. The model of APN specialist transitional care
(comprehensive discharge planning and home follow-up
to high risk, high cost, high volume patient groups)
was developed to improve post-discharge outcomes among
this vulnerable patient group.
APN
transitional care was used to substitute for routine
hospital-based discharge planning and, if referred,
home care. The effects of this intervention on quality
as reflected in patient and caregiver outcomes and costs
were examined. Chief findings from the first major study
were that a discharge planning intervention reduced
hospitalizations for medical cardiac patients for six
weeks post-discharge. . A second major study expanded
the intervention to include a 4-week home follow-up
and successfully demonstrated improved clinical outcomes
and decreased hospital readmissions for common medical
and surgical conditions. The preceding study, however,
failed to demonstrate long-term improvements with heart
failure patients, who reported great difficulty with
medications, diet, activity regimen, and management
of symptoms at the end of the 4 week period. Thus, a
third study was undertaken to test a comprehensive,
longer-term intervention targeted elderly patients with
heart failure. This study has recently been completed.
| SELECTED
PUBLICATIONS on APN TRANSITIONAL CARE |
A
Decade of Transitional Care Research with Vulnerable
Elders
Mary D. Naylor, PhD, RN, FAAN
Abstract:
Contributions
to knowledge development and clinical practice during
the past decade resulting from testing and refining
a transitional care model with hospitalized elders by
a multidisciplinary research team is described. A major
goal of this research program has been to improve the
post-discharge outcomes of older adults admitted to
hospitals for an acute exacerbation of a chronic cardiovascular
illness. In addition to demonstrating positive outcomes
for elders while reducing costs, findings from the testing
of the transitional care model have advanced knowledge
of important patient and caregiver issues including
the effects of the model of elders with medical versus
surgical conditions, the profile of elders at risk for
poor outcomes, predictors of caregiver burden, the unique
needs of elders and the contributions of advanced practice
nurses in meeting these needs, and decision making regarding
home care referrals.
Key words: advanced practice nurses, discharge planning,
home care, hospitalized elders, transitional care.
From:
Journal of Cardiovascular Nursing 2000: 14
(13):1-14.
Comprehensive
Discharge Planning and Home Follow-up of Hospitalized
Elders: A Randomized Clinical
Trial
Mary
D. Naylor, PhD; Dorothy Brooten, PhD; Roberta Campbell,
MSN; Barbara S. Jacobson, MS; Mathy D. Mezey, EdD; Mark
V. Pauly, PhD; J. Sanford Schwartz, MD
Abstract:
To examine the effectiveness
of an advanced practice nurse-centered discharge planning
and home follow-up intervention for elders at risk for
hospital readmission, a comprehensive discharge planning
and home follow-up protocol was designed and implemented
by advanced practice nurses. These interventions reduced
readmissions, lengthened the time between discharge
and readmission, and decreased the costs of providing
health care. Thus, advanced practice nurse-centered
interventions have great potential in promoting positive
outcomes for hospitalized elders at high risk for rehospitalization
while reducing costs.
From:
JAMA, February 17, 1999: 281(7): 613-620.
Comprehensive
Discharge Planning for the Hospitalized Elderly:
A Randomized Clinical Trial
Mary Naylor, PhD; Dorothy Brooten, PhD; Robert
Jones, PhD; Risa Lavizzo-Mourey, MD, MBA; Mathy Mezey,
EdD; and Mark Pauly, PhD.
Abstract:
A
randomized clinical trial involving 276 patients and
125 caregivers was launched
to study the effects of a comprehensive discharge
planning protocol, designed specifically for the elderly
and implemented by nurse specialists, on patient and
caregiver outcomes and cost of care. Patients were
70 years and older, were placed in selected medical
and surgical cardiac diagnostic-related groups. From
the initial hospital discharge to 6 weeks after discharge,
patients in the medical intervention group had fewer
readmissions, fewer total days rehospitalized, lower
readmission charges, and lower charges for health
care services after discharge.
Findings support the need for comprehensive discharge
planning designed for the elderly and implemented
by nurse specialists to improve their outcomes after
hospital discharge and to achieve cost savings.
From:
Annals of Internal Medicine, 15 June 1994:
120(12):999-1006.
| PUBLICATIONS
on Advanced Practice Nursing |
Naylor,
M. (2002). Transitional Care of Older Adults (pp.127-147)
IN: P. Archbold, & B. Stewart (Eds.). Annual
Review of Nursing Research, Vol. 20. New York: Springer.
Naylor,
M., Bowles, K., Campbell, R., & McCauley, K. (2001).
Discharge planning: Design and Implementation. (pp.
197-212). In T. T. Fulmer, M.D. Foreman, M. Walker,
& K.S. Montgomery (Eds.). Critical Care Nursing
of the Elderly. (2nd ed.). New York: Springer.
Naylor,
M. (2000). A Decade of Transitional Care Research with
Hospitalized Elders. Journal of Cardiovascular Nursing,
14(3), 1-14.
Naylor,
M., Bowles, K., & Brooten, D. (2000). Patient Problems
and Advanced Practice Nurse Interventions During Transitional
Care. Public Health Nursing, 17(2), 94-102.
Naylor,
M., & McCauley, K. (1999). The Effects of a Discharge
Planning and Home Follow-Up Intervention on Elders Hospitalized
with Common Medical and Surgical Conditions. Journal
of Cardiovascular Nursing, 14(1), 44-54.
Naylor,
M. Brooten, D., Campbell, R., Jacobsen, B., Mezey, M.,
Pauly, M. & Schwartz, J. (1999). Comprehensive Discharge
Planning and Home Follow-Up of Hospitalized Elders:
A Randomized Controlled Trial. Journal of the American
Medical Association, 281(7), 613-620.
Naylor,
M., & Roe-Prior, P. (1999). Transitions Between
Acute and Long Term Care. In P.R. Katz. M. Mezey and
R. Kane (Eds.) Advances in Long Term Care. Volume
IV. New York: Springer, 1-22.
Naylor,
M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey,
M., & Pauly, M. (1994). Comprehensive Discharge
Planning for the Hospitalized Elderly: A Randomized
Clinical Trial. Annals of Internal Medicine,
120(12), 999-1006.
Naylor,
M., & Brooten, D. (1993). Roles and Functions of
Clinical Nurse Specialists: State of the Science. Image:
Journal of Nursing Scholarship, 25(2), 99-104.
Naylor,
M. (1990). Comprehensive Discharge Planning for Hospitalized
Elderly: A Pilot Study. Nursing Research, 39(3),
156-160.
"APNs
Make a Difference" (Nursing Spectrum)
"Getting
Patients Back on Their Feet Faster"
(Washington Post)
"A
Simple Plan Discharge planning improves the odds"
(Nurseweek)
"Aggressive
discharge plan cuts readmissions, slashes costs"
(Thompson AHC)
"Mary
Naylor: Champion of Research" (Nursing
Spectrum)
Transitional
Care for Older Adults: A Cost-Effective Model
(LDI Issues Brief)
Series: Transitions in Health premieres
9/15 in the Research
Channel Video Library
| FOR
MORE INFORMATION about Advance Practice Nursing
Interventions, please contact |
Mary
D. Naylor, PhD, RN, FAAN,
Marian S. Ware Professor in Gerontology
University of Pennsylvania
School of Nursing
Philadelphia, PA 19104
naylor@nursing.upenn.edu
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