A Qualitative Analysis of an Advanced Practice Nurse-Directed Transitional Care Model Intervention

Abstract

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

Transitional care model: managing the experience of hospital at home

“…It should be noted that all these components are in constant communication with each other and are essential components of comprehensive care process. Each of the core components of transitional care model is defined in the Table 1 (2,4,10).…”

“…Factors such as functional status, cognitive status, mental health, physical status, life quality, family needs and health are also assessed (2,5,10).…”

“…In particular, evidence-based transitional care that meets care needs of patient at the time of hospitalization is an accepted approach that is emphasized in the chronically ill and the elderly (6)(7)(8). One of the approaches tested in this regard is transitional care model that promotes the health of patients with chronic diseases and has a positive economic effect on the patient and family (9)(10)(11). In this care model, nursing care and providing it to patients with chronic diseases during hospitalization and then at home is offered and guided by the nurse.…”

Umsorgt werden und umsorgen: Leben mit mehreren Langzeiterkrankungen (Leila) – Eine qualitative Studie zum Beitrag von APN in integrierter Versorgung

“…Die Literatur bestätigt, dass APNs wesentliche Beiträge zu Informationsvermittlung, Koordination und zur Gestaltung von Übergängen leisten, was von Patient(inn)en als für-sorglich bezeichnet wird (Bradway et al, 2012). Demgegenüber erfuhren die Pflegeexpertinnen APN seitens der Zuweisenden manchmal Zurücksetzung oder Unterordnung.…”

An Analysis of Methodologies That Can Be Used to Validate if a Perioperative Surgical Home Improves the Patient-centeredness, Evidence-based Practice, Quality, Safety, and Value of Patient Care

“…28 A key element of this perioperative Transitional Care Model is a nurse clinician (or medical social worker) serving as the patient's "perioperative transitions coach." 29,30 The implementation of such a PSH model will likely also be an evolutionary process that varies across local practice environments. Because a given PSH evolves from the existing local model of care, different institutions may well adopt different elements at different rates, with variable emphasis on specific surgical populations (e.g., total joint replacement) or specific portions of the perioperative continuum of care (e.g., preoperative medical optimization and patient education and counseling).…”