title: Transitional Care Partners: a hospital-to-home support for older adults and their caregivers.
abstract: OBJECTIVE
  To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans.
  
  
  METHODS
  Hospital records of TLC patients to track their hospital and emergency department visits before and after the TLC Partners enrollment. Caregivers of patients completed Preparedness in Caregiving and the Short Form Zarit Burden Scale during the first week of the TLC Partners enrollment and on the week when the services ended.
  
  
  CONCLUSIONS
  The proportion of patients with one or more emergency department visits and rehospitalization is consistently lower among TLC patients compared to non-TLC patients at 30 and 60 days of hospital discharge. The mean preparedness and burden scores before and after the program essentially remained the same.
  
  
  CONCLUSIONS
  The description of the implementation of the TLC Partners offers an example of how nurse practitioner-led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models.
authors.affiliation: (Nurse Investigator), (Social Worker), (Physician), Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina (Nurse Investigator), Duke University School of Nursing, Durham, North Carolina (Nurse Investigator), (Physician), Duke University Center for the Study of Aging and Human Development, Durham, North Carolina (Nurse Practitioner), (Occupational Therapist), (Physician), Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina (Physician), Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina (Physician), Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina.
authors.forename: Cristina
authors.initials: C
authors.lastname: Hendrix
authors.forename: Sara
authors.initials: S
authors.lastname: Tepfer
authors.forename: Sabrina
authors.initials: S
authors.lastname: Forest
authors.forename: Karen
authors.initials: K
authors.lastname: Ziegler
authors.forename: Valerie
authors.initials: V
authors.lastname: Fox
authors.forename: Jeannette
authors.initials: J
authors.lastname: Stein
authors.forename: Eleanor S
authors.initials: ES
authors.lastname: McConnell
authors.forename: Susan Nicole
authors.initials: SN
authors.lastname: Hastings
authors.forename: Kenneth
authors.initials: K
authors.lastname: Schmader
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colon-Emeric
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004636:Emergency Service, Hospital; D005260:Female; D006301:Health Services Needs and Demand; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D010359:Patient Readmission; D015397:Program Evaluation
keywords: Geriatric; caregiver; home care; nurse practitioners; transitional care model; veterans' health