title: Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial.
abstract: OBJECTIVE
  To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure.
  
  
  METHODS
  Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge.
  
  
  METHODS
  Six Philadelphia academic and community hospitals.
  
  
  METHODS
  Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure.
  
  
  METHODS
  A 3-month APN-directed discharge planning and home follow-up protocol.
  
  
  METHODS
  Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care.
  
  
  RESULTS
  Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001).
  
  
  CONCLUSIONS
  A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.
authors.affiliation: Gerontological Nursing Science Center, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA. naylor@nursing.upenn.edu
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Brooten
authors.forename: Roberta L
authors.initials: RL
authors.lastname: Campbell
authors.forename: Greg
authors.initials: G
authors.lastname: Maislin
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: McCauley
authors.forename: J Sanford
authors.initials: JS
authors.lastname: Schwartz
mesh_terms: D001741:Black or African American; D000359:Aftercare; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D016001:Confidence Intervals; D003266:Continuity of Patient Care; D003365:Costs and Cost Analysis; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000191:economics / Q000401:mortality / Q000451:nursing / Q000628:therapy*; D006699:Home Care Services; D006760:Hospitalization; D006801:Humans; D008297:Male; D010359:Patient Readmission; D017060:Patient Satisfaction; D011788:Quality of Life; D012044:Regression Analysis; D012959:Socioeconomic Factors; D013997:Time Factors; D016896:Treatment Outcome; D044465:White People