title: A qualitative analysis of an advanced practice nurse-directed transitional care model intervention.
abstract: OBJECTIVE
  The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).
  
  
  METHODS
  APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.
  
  
  RESULTS
  Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.
  
  
  CONCLUSIONS
  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.
authors: University of Pennsylvania School of Nursing, Philadelphia, USA. cwb@nursing.upenn.edu
authors: Christine
authors: C
authors: Bradway
authors: Rebecca
authors: R
authors: Trotta
authors: M Brian
authors: MB
authors: Bixby
authors: Ellen
authors: E
authors: McPartland
authors: M Catherine
authors: MC
authors: Wollman
authors: Heidi
authors: H
authors: Kapustka
authors: Kathleen
authors: K
authors: McCauley
authors: Mary D
authors: MD
authors: Naylor
mesh_terms: D057179:Advanced Practice Nursing; D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers / Q000193:education / Q000523:psychology; D003072:Cognition Disorders / Q000451:nursing*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D055318:Evidence-Based Nursing; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006699:Home Care Services / Q000458:organization & administration; D006801:Humans; D008297:Male; D008875:Middle Aged; D016294:Models, Nursing; D009722:Nurse Practitioners; D010360:Patient Transfer; D018802:Patient-Centered Care / Q000458:organization & administration*; D036301:Qualitative Research