Purpose-To describe the development, testing, modification, and results of the Quality Cost Model of Advanced Practice Nurses (APNs) Transitional Care on patient outcomes and health care costs in the United States over 22 years, and to delineate what has been learned for nursing education, practice, and further research.Organizing Construct-The Quality Cost Model of APN Transitional Care.Methods-Review of published results of seven randomized clinical trials with very low birthweight (VLBW) infants; women with unplanned cesarean births, high risk pregnancies, and hysterectomy surgery; elders with cardiac medical and surgical diagnoses and common diagnostic related groups (DRGs); and women with high risk pregnancies in which half of physician prenatal care was substituted with APN care. Ongoing work with the model is linking the process of APN care with the outcomes and costs of care. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptFindings-APN intervention has consistently resulted in improved patient outcomes and reduced health care costs across groups. Groups with APN providers were rehospitalized for less time at less cost, reflecting early detection and intervention. Optimal number and timing of postdischarge home visits and telephone contacts by the APNs and patterns of rehospitalizations and acute care visits varied by group.Conclusions-To keep people well over time, APNs must have depth of knowledge and excellent clinical and interpersonal skills that are the hallmark of specialist practice, an in-depth understanding of systems and how to work within them, and sufficient patient contact to effect positive outcomes at low cost. Keywordsadvanced practice nurses; Quality Cost Model; transitional care; costs; outcomes Dramatic changes in health care have occurred over the past 2 decades resulting in merged health systems, shortened hospital stays, rapid growth of outpatient and home care services and changed systems of reimbursement (Lesser & Ginsburg, 2001). The goal is to provide the most effective health care services at the lowest cost. Examining the effectiveness of health care providers has accompanied these changes. Today's data-driven health care systems require that provider practices are based on evidence and that provider time and number of patient contacts be justified (Delaney, Reed, & Clarke, 2000).In 1980, responding to changes occurring in health care, a team of researchers at the University of Pennsylvania developed a model of transitional care delivered by advanced practice nurses (APNs) that could serve as a safety net for vulnerable patient groups being discharged early from hospitals; this approach might maintain quality care and reduce health care costs . Since 1980 research with this model of care has been conducted in two phases. The first phase, which remains ongoing, focused on testing, refining, and modifying the model for use with different patient groups. Consistent success in improving patient outcomes and reducing health care costs in patient gr...

Purpose-To describe patient problems and APN interventions in each of five clinical trials and to establish links among patient problems, APN interventions, APN time and number of contacts, patient outcomes, and health care costs.Design and Methods-Analysis of 333 interaction logs created by APNs during five randomized controlled trials: (a) very low birthweight infants (n=39); (b) women with unplanned cesarean birth (n=61), (c) high-risk pregnancy (n=44), and (d) hysterectomy (n=53); and (e) elders with cardiac medical and surgical diagnoses (n=139). Logs containing recordings of all APN interactions with participants, APN time and type of patient contact were content analyzed with the smallest phrase or sentence representing a "unit." These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Groups were compared concerning total amount of APN time, number of contacts per patient, and mean length of time per APN contact. All studies were conducted in the United States.Findings-Groups with greater mean APN time and contacts per patient had greater improvements in patients' outcomes and greater health care cost savings. Of the 150,131 APN interventions, surveillance was the predominant APN function in all five patient groups. Health teaching, guidance, and counseling was the second most frequent category of APN intervention in four of the five groups. In all five groups, treatments and procedures accounted for <1% of total APN interventions. Distribution of patient problems (N=150,131) differed across groups reflecting the health care problems common to the group.Conclusions-Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessing, teaching, counseling, communicating, collaborating, knowing health behaviors, negotiating systems, and having condition-specific knowledge about different patient problems.

Future nurse home-visiting research should test a combination of these effective components. Nurses can use this information to seek funding of nurse-delivered interventions for vulnerable families.

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In a randomized clinical trial, quality of health care as reflected in patient outcomes and cost of health care was compared between two groups of high-risk childbearing women: women diagnosed with diabetes or hypertension in pregnancy. The control group (N = 52) was discharged routinely from the hospital. The intervention group (N = 44) was discharged early using a model of clinical nurse specialist transitional follow-up care. During pregnancy, the intervention group had significantly fewer rehospitalizations than the control group. For infants of diabetic women enrolled in the study during their pregnancy, low birth weight (< or = 2,500 g) was three times more prevalent in the control group (29%) than in the intervention group (8.3%). The postpartum hospital charges for the intervention group were also significantly less than for the control group. The mean total hospital charges for the intervention group were 44% less than for the control group. The mean cost of the clinical specialist follow-up care was 2% of the total hospital charges for the control group. A net savings of $13,327 was realized for each mother-infant dyad discharged early from the hospital.