Florida Panhandle Nurse Practitioner Coalition

Advanced Practice Nurses Can Help Lead Transitional Care

Posted about 14 years ago by Stanley F Whittaker

Seeking to address the human and financial burden of revolving-door hospital readmissions, the Affordable Care Act proposes a number of initiatives to improve care and health outcomes and reduce costs for the growing population of chronically ill people in the U.S.

While transitional care is a central theme in these provisions, little information is available to guide those responsible for implementing these opportunities. To bridge the gap, researchers at the University of Pennsylvania School of Nursing reviewed existing programs to determine what works, for whom and for how long. They discovered “a robust body of evidence” that transitional care can improve health outcomes and reduce hospital readmissions.

The review shows that among the common elements of successful transitional care programs is the role of nurses, often master’s prepared, who work with patients, family caregivers and health teams to prevent medical errors and assure continuity of care as patients navigate a fragmented healthcare system.

“All nine interventions that showed any positive impact on readmissions relied on nurses as the clinical leader of manager care,” wrote lead author Mary Naylor, RN, PhD, a professor at the University of Pennsylvania School of Nursing.

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