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Translating
Research into Practice:
A Focus on Care Coordination
Mary
D. Naylor, PhD, FAAN, RN
A growing body of science suggests that older adults coping
with multiple chronic conditions and complex therapies are
particularly vulnerable to breakdowns in care. Insufficient
communication among providers and across health care agencies,
inadequate patient and caregiver education, poor continuity
of care, and limited access to services are among the major
factors contributing to negative quality and cost outcomes.
Rehospitalization rates for these patients are very high, with
one-quarter to one-third considered preventable. A recent Institute
of Medicine report identified care coordination as one of 20
national priorities for action.
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 funded
randomized clinical trials have consistently demonstrated
the ability of this care model to improve quality and substantially
decrease health care costs. However, this research-based
approach to care has not been integrated into clinical practice.
Given the projected growth of the population of older adults
with complex care needs in the next few decades, there is
a critical need to bridge the chasm between evidence-based
best practices in care coordination and the current approach
to such care.
In response
to this challenge, the Penn research team has formed a partnership
with the Aetna Corporation to utilize product development
and marketing approaches in order to achieve the following
goals: promote rapid adoption of the APN Care Model by a
major health care insurance corporation; package the APN
Care Model in a manner that enables widespread adoption by
other insurers and health systems;document the barriers and
facilitators to diffusing this innovation in a corporate
setting; and facilitate needed changes in health policy to
support reimbursement of this approach to care.
The outcomes of this project are designed to substantially
improve the coordination of care and outcomes of a growing
population of high risk older adults by informing and influencing
decision-making at the clinical, organizational, health system
and public policy levels regarding the quality and cost benefits
associated with translation of the APN Care Model, a research
based innovation, into clinical practice.
This
Project is funded by the Commonwealth Fund and the Jacob & Valeria
Langeloth Foundation
For more
information, please contact Dr.
Mary Naylor or Brian
Bixby,
project manager.
| The
above listed initiative is just one of many
ongoing studies or projects by our Penn Nursing
scholars. For
more information on other Penn Nursing experts,
or to
request a CONSULTATION, please contact |
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