1. Kennedy, Maureen Shawn MA, RN

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A study by researchers at the University of Pennsylvania reveals that older adults hospitalized with heart failure-a population that accounts for an annual direct health care expenditure of about $24.3 billion-stay healthier, and for longer, if they receive comprehensive transitional care from advance practice nurses (APNs) during hospitalization and after discharge. The APNs all had graduate-level educations and were given two months of additional training in the provision of evidence-based care to elderly patients.


Researchers randomly placed 121 patients hospitalized with heart failure in a control group and another 118 patients, matched for sociodemographic and clinical characteristics, in an intervention group. While the control group received routine hospital care and discharge planning, the intervention group received, in addition to routine care, a visit from an APN within 24 hours of hospitalization, daily visits during hospitalization, and at least eight home visits for a year. APNs were also available by telephone seven days a week.

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At one year, the rates of rehospitalization and death were lower in the intervention group than in the control group, and patients in the intervention group were free of adverse events for longer; overall costs were also lower in the intervention group.


Fair reimbursement for APN services.

"Medicare should reimburse research-based care," says Mary Naylor, lead author of the study and professor at the University of Pennsylvania School of Nursing. She says that the absence of such reimbursement is a major barrier to improving the quality of the care the elderly receive. In addition, she says, four elements are critical to the success of a transition plan: "using nurses to manage care, tailoring interventions to the needs of each patient, establishing strong collaboration between nurses and physicians, and enhancing the continuity of care." According to a press release from the National Institutes of Health (the study was funded by the National Institute of Nursing Research), pilot programs based on the model employed in the study will be implemented in Delaware, New Jersey, and Pennsylvania later this year.-Dalia Sofer


Naylor M, et al. J Am Geriatr Soc 2004);52(5):675-84.