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This study evaluates the effectiveness of a transitional care intervention for patients aged 65 and older, focusing on those with chronic diseases. Over the course of a year, 158 patients were assessed with the assistance of a nurse practitioner acting as a transition coach. The coach engaged with patients and caregivers to enhance understanding of care protocols and foster active roles during transitions. The results indicate that patients involved in the intervention had a significantly lower rate of rehospitalization, highlighting the importance of patient education and engagement in transitional care.
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Interventions That Improve Transitional Care and Reduce Readmission Rates Madison Griffin, BSN Student Chealsey Brock, BSN Student Introduction Results Methods • 158 patients aged 65 years or older initially hospitalized with a chronic disease. • Evaluated over a year span • Nurse practitioner was employed as a transition coach • Transition coach communicated with the patient and their caregiver concerning treatment and education • . To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates. Interventions & Conclusion • medication self-management • a patient-centered record • primary care and specialist follow-up • knowledge of ‘‘red flags’’ warning symptom or sign indicative of a worsening condition • *Patients involved in intervention were half as likely to return to the hospital as those who were not References • Your text goes here.
