Journal of Gerontological Nursing

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Studying Home Follow-up of Cardiac Patients

Abstract

The University of Pennsylvania School of Nursing has been awarded a $2.6 million grant from the National Institute of Health, National Institute of Nursing Research (NEMR) for a 4-year study, "Home Follow-up of Elderly Patients with Heart Failure."

This randomized clinical trial builds directly on two previous NINR-funded studies conducted at the School of Nursing which tested the QualityCost Model of Advanced Practice Nurse (APN) Transitional Care on elderly patients. Prior and ongoing studies have demonstrated improved outcomes and decreased costs of care for all patient groups except those with heart failure.

According to Mary Naylor, PhD, FAAN, Associate Professor of Nursing and the principal investigator of this study, earlier testing of this model of comprehensive discharge planning and home follow-up by APNs suggested that patients with heart failure require a longer, more intensive nursing intervention to manage the symptoms, treatment, and effects of heart failure and to improve general health behaviors.

Researchers will compare patient outcomes and cost of care between two groups of patients: a control group that will receive traditional discharge planning and, if referred, routine home care and an intervention group that will receive a comprehensive program of discharge planning and home follow-up coordinated and implemented by APNs.

Patients in the intervention group will be visited within 24 hours of hospital admission and at least daily for assessment of their goals and development and implementation of an individualized plan to guide discharge planning and home follow-up. Following discharge, at least weekly contacts by APNs via home visits or telephone will be provided. Daily availability of APNs will extend from hospital admission through 3 months postdischarge. Patients in both groups will be followed for 1 year to compare quality and cost outcomes.

Naylor stresses that "the findings of this study will guide optimal care of elderly patients with heart failure and will be potentially useful in the development of similar interventions in patients with other chronic conditions characterized by high morbidity and complex management regimens. Study findings may also influence the use of APNs working in collaboration with physicians and a multidisciplinary team in long-term management of chronically ill patients."…

The University of Pennsylvania School of Nursing has been awarded a $2.6 million grant from the National Institute of Health, National Institute of Nursing Research (NEMR) for a 4-year study, "Home Follow-up of Elderly Patients with Heart Failure."

This randomized clinical trial builds directly on two previous NINR-funded studies conducted at the School of Nursing which tested the QualityCost Model of Advanced Practice Nurse (APN) Transitional Care on elderly patients. Prior and ongoing studies have demonstrated improved outcomes and decreased costs of care for all patient groups except those with heart failure.

According to Mary Naylor, PhD, FAAN, Associate Professor of Nursing and the principal investigator of this study, earlier testing of this model of comprehensive discharge planning and home follow-up by APNs suggested that patients with heart failure require a longer, more intensive nursing intervention to manage the symptoms, treatment, and effects of heart failure and to improve general health behaviors.

Researchers will compare patient outcomes and cost of care between two groups of patients: a control group that will receive traditional discharge planning and, if referred, routine home care and an intervention group that will receive a comprehensive program of discharge planning and home follow-up coordinated and implemented by APNs.

Patients in the intervention group will be visited within 24 hours of hospital admission and at least daily for assessment of their goals and development and implementation of an individualized plan to guide discharge planning and home follow-up. Following discharge, at least weekly contacts by APNs via home visits or telephone will be provided. Daily availability of APNs will extend from hospital admission through 3 months postdischarge. Patients in both groups will be followed for 1 year to compare quality and cost outcomes.

Naylor stresses that "the findings of this study will guide optimal care of elderly patients with heart failure and will be potentially useful in the development of similar interventions in patients with other chronic conditions characterized by high morbidity and complex management regimens. Study findings may also influence the use of APNs working in collaboration with physicians and a multidisciplinary team in long-term management of chronically ill patients."

10.3928/0098-9134-19970301-03

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