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Redefining the future of health transitions

Meeting the complex health care needs of individuals living with chronic illnesses such as heart failure, diabetes and depression in a person-centered, safe, and efficient manner will be a, if not the, dominant healthcare challenge in the next few decades. Our research agenda focuses on the growing population of chronically ill adults with a specialization on frail, elderly adults and their family caregivers. Members’ implementation of various research methods is now creating a body of knowledge that will directly benefit this vulnerable population. 


Mother and daughter holding hands in a hospital supporting each other

End-of-life Health-Care Utilization Patterns Among Chronically Ill Older Adults

Study authors of the first online paper in the American Journal of Hospice and Palliative Medicine examined the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in complex care management. Utilization of health-care services continue to rise at end of life, i.e., hospitalizations rose sharply in the last 3 months of life, and for certain types of diagnoses.

New study on self-care among informal caregivers

Congratulations to Barbara Riegel and her team for a new National Institute for Nursing Research funded randomized controlled trial, “Improving self-care of informal caregivers of adults with heart failure,” testing the efficacy of a health coaching intervention delivered virtually using tablets. The ultimate goal of this work is to help caregivers take better care of themselves. Study team:  Kathryn H. Bowles, PhD, RN, FAAN, FACMI, Professor of Nursing and van Amerigen Chair in Nursing Excellence; Joyce W. Wald, DO, Associate Director, Mechanical Circulatory Support Program (Penn Medicine); Karen B. Hirschman, PhD, MSW, Research Associate Professor; Alexandra Hanlon, PhD, Adjunct Professor of Nursing.