Elderly patients with heart failure present a tremendous challenge to the current health care system. Decreased length of hospital stay for patients with increased numbers of comorbid conditions and complex medication regimens contribute to a revolving door of rehospitalizations. Using a transitional care model designed to decrease rehospitalizations, advanced practice nurses (APNs) in an ongoing clinical trial provide discharge planning in the acute care setting with home follow-up by the same APN for a 3-month period. This article reviews three case studies to provide a view of the complex and challenging situations in which elders with heart failure live and the care provided by APNs using the transitional care model to guide their practice. Social, economic, and emotional factors overlay the illness in each of these cases. The APNs, with advanced knowledge of cardiac disease and research-based management, help the patients and their caregivers to prioritize information and take the appropriate actions, while coping with the complexity of their conditions and the challenges they face. Keeping these patients from returning to the hospital provides evidence of the success of this transitional model of care.

Service coordinators in a statewide early intervention program were surveyed to develop an understanding of screening and referral practices to identify children on the autism spectrum. Quantitative and qualitative data summarizing autismspecific screening and referral practices are reported. More than 50% of the respondents reported that they had never received a referral from a physician or another early intervention provider because a child has failed an autism-specific screening. While service coordinators identified that early intervention providers have a role in conducting autism-specific screening, more than 50% of the respondents indicated that they do not see autism-specific screening completed in early intervention settings. More than 80% of the respondents identified "a lack of knowledge" as the most significant barrier to autism-specific screening. Together, these findings suggest that early intervention providers may benefit from professional development that imparts knowledge, teaches skills, and addresses potential concerns of parents related to autism.

Heart failure continues to be a challenge for older patients and their health care providers. This article is based on work by advanced practice nurses in a nursing study funded by the National Institute of Nursing Research of the National Institute of Health. Mary Naylor, RN, PhD at the University of Pennsylvania School of Nursing through grant #1RO1-NR04315 is using a transitional care model to provide advance practice nurse intervention for older adults with heart failure in a randomized controlled trial. Effects of the intervention being addressed include quality of life, functional status, rehospitalizations, and costs of care. Working with the patient in the acute hospital setting and following patients to the home care setting for 3 months, the advance practice nurse develops a visit pattern and intervention plan individual to the patient's needs. Key to a successful intervention plan is the right treatment for systolic versus diastolic failure. Although the patient's symptoms and some physical findings may be similar, the drugs used to treat systolic versus diastolic heart failure are different. Thus the nursing interventions to promote symptom management and avoid rehospitalizations have a different approach. In this article, care of elderly individuals with systolic versus diastolic heart failure is compared and contrasted using physical examination and diagnostic techniques, medication management, and nursing intervention. Case studies of a typical patient with systolic and diastolic heart failure will be used to illustrate the differences in approach to this common group of patients with complex needs.