Abstract
Elderly patients with heart failure present a tremendous challenge to the current health care system. Decreased length of hospital stay for patients with increased numbers of comorbid conditions and complex medication regimens contribute to a revolving door of rehospitalizations. Using a transitional care model designed to decrease rehospitalizations, advanced practice nurses (APNs) in an ongoing clinical trial provide discharge planning in the acute care setting with home follow-up by the same APN for a 3-month period. This article reviews three case studies to provide a view of the complex and challenging situations in which elders with heart failure live and the care provided by APNs using the transitional care model to guide their practice. Social, economic, and emotional factors overlay the illness in each of these cases. The APNs, with advanced knowledge of cardiac disease and research-based management, help the patients and their caregivers to prioritize information and take the appropriate actions, while coping with the complexity of their conditions and the challenges they face. Keeping these patients from returning to the hospital provides evidence of the success of this transitional model of care.