Effects of alternative interventions among hospitalized, cognitively impaired older adults

Naylor, Mary D.; Hirschman, Karen B.; Hanlon, Alexandra L.; Bowles, Kathryn H.; Bradway, Christine; McCauley, Kathleen M.; Pauly, Mark V.

doi:10.2217/cer-2015-0009

Cited by 10 publications

(29 citation statements)

References 60 publications

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“…Naylor and colleagues (Naylor et al., , ) have demonstrated that the advanced practice nurse (APN) can play a central role during the transition period after heart failure and with cognitively impaired older adults. A variation of Naylor's Transitional Care Model (TCM) could be an important approach for ISSs.…”

Section: Discussionmentioning

confidence: 99%

Stroke survivors’ experiences transitioning from hospital to home

Connolly

Mahoney

2018

Journal of Clinical Nursing

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Section: Discussionmentioning

confidence: 99%

Stroke survivors’ experiences transitioning from hospital to home

Connolly

Mahoney

2018

Journal of Clinical Nursing

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“…In search of high‐level research in transitional care, we also identified four well‐designed studies without randomization. These studies focused on NP‐led interventions for community‐dwelling older adults at high risk of rehospitalization (Condon, Lyca, Duncan, & Bushnell, ; Deniger, Troller, & Kennelty, ; Naylor et al., ; Ornstein, Smith, Foer, Lopez‐Cantor, & Soriano, ). Risk was determined by a combination of cognitive and physical functioning, polypharmacy, social support deficits, falls history, comorbidities, and high‐risk medications.…”

Section: Evidence Reviewmentioning

confidence: 99%

“…Naylor et al. () assessed patients with a diagnosis of dementia or cognitive deficits in a nonrandomized confirmatory study to test the efficacy of TCM‐based interventions on cognitively impaired adults (Table ). Condon et al.…”

Section: Evidence Reviewmentioning

confidence: 99%

“…In three of the studies, hospitalized older adults were assessed by an NP at the hospital bedside and subsequently at home (Deniger et al., ; Naylor et al., ; Ornstein et al., ). Similar to the landmark study by Naylor et al.…”

Section: Evidence Reviewmentioning

confidence: 99%

“…In the landmark study, patients received home visits by an APN within 24 h of discharge (Naylor et al., ). In subsequent studies, the NPs performed home assessments between 1 and 5 days after discharge (Deniger et al., ; Naylor et al., ; Ornstein et al., ). APNs were available via phone calls for 90 days post discharge in the landmark study (Naylor et al, ), while NPs were available 30–60 days post discharge in other studies (Deniger et al., ; Naylor et al., ; Ornstein et al., ).…”

Section: Evidence Reviewmentioning

confidence: 99%

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Nurse practitioner-led transitional care interventions: An integrative review

Mora

Dorrejo

Carreon

et al. 2017

Journal of the American Association of Nurse Practitioners

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Background and purpose Chronically ill patients 65 and above have an increased risk of preventable readmission within 30 days of discharge from the hospital. The Transitional Care Model (TCM) introduced by Naylor and colleagues was implemented to improve the transition between hospital and home while decreasing readmissions. This article examines whether nurse practitioner (NP)‐ led TCM interventions as compared to standard care decrease hospital readmission rates in older adults. Methods A literature review was conducted from June 2016 to March 2017 using Cochrane Library, PubMed, Cumulative Index to Nursing and Health Literature (CINAHL) PLUS, Joanna Briggs Institute, and ProQuest Central to seek out the highest level of evidence. Search results were refined to focus on randomized control trials (RTCs) containing NP‐led TCM interventions with older adults. Conclusions Synthesis of three RTCs, one meta‐analysis, and four nonrandomized studies reviewed TCM interventions that included these interventions: follow‐up phone calls post discharge, home visits, and handoff of information to the patient's primary care provider. These interventions, although not exclusively led by NPs, decreased hospital readmission rates. Implications for practice NP‐led TCM interventions have the potential to decrease readmissions, but the level of evidence is insufficiently high to allow for generalizability, warranting further study.

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An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Hirschman

McHugh

Morgan

2023

A&D Transl Res & Clin Interv

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IntroductionHigh rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.MethodsThis integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person‐ and family‐centered.ResultsSeventy‐one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health‐care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person‐ and family‐centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.DiscussionTransitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health‐care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

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Effects of alternative interventions among hospitalized, cognitively impaired older adults

Abstract: Findings suggest the TCM is more effective than ASC. However, potential effects of the RNC relative to the TCM warrant further study.

Cited by 10 publications

References 60 publications

Stroke survivors’ experiences transitioning from hospital to home

Stroke survivors’ experiences transitioning from hospital to home

Nurse practitioner-led transitional care interventions: An integrative review

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

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