Ideally, transitional care is a clinical intervention that includes comprehensive, individualized assessment, and discharge planning with appropriate decision making and referral to assist the movement of patients from one level of care to another. It should include clear communication, coordination, and feedback among multidisciplinary care providers and effective education and achievement of behavioral modification for patients and caregivers to self-manage and monitor their conditions. However, today's cost-conscious health care environment and current practice models often do not provide the time and resources to achieve this ideal. Pressures to control costs generated from the prospective payment system have forced discharge planners to speed up all aspects of care to achieve timely discharge. Patients are often discharged before the full effect of treatment is evident, before the patient and family fully understand the illness or the treatment plan, and before the patient can assume self-care. 1 In addition, evidence-based models of transitional care are often not widely disseminated or their implementation is constrained by current reimbursement policies. This reality makes it all the more important to highlight successes in transitional care and share the advice of experts who have attempted to achieve the ideal.
This issue of The Journal of Cardiovascular Nursing (14:3) includes accounts of several impressive examples of successful transitional care strategies. The authors address some of the key issues in transitional care including research-based models of care, significant aspects of communication and continuity, identification of patient problems and nurse interventions, and clinically relevant examples of patient and caregiver education and satisfaction.
In the first article, Naylor describes the development, testing, and refinement of a model of transitional care over the past decade and celebrates the achievements of advanced practice nurses (APNs) as they implement a comprehensive, multidisciplinary discharge planning and home follow-up program for vulnerable elders. In addition to demonstrating positive outcomes for elders while reducing costs, Naylor and her colleagues have advanced the understanding of important patient and caregiver issues including the effects of the model on elders with medical versus surgical conditions, the profile of elders at risk for poor outcomes, predictors of caregiver burden, the unique needs of elders and the contributions of APNs in meeting these needs, and decision making regarding home care referrals. This model of transitional care, and the knowledge generated from its testing, provides invaluable guidance for restructuring the way transitional care is currently provided. The impressive outcomes achieved with this model approach the ideal of comprehensive, efficient, and effective transitional care.
One of the largest challenges to effective transitional care is the breakdown in communication and continuity. Anderson and Helms are leaders in the area of communication and continuity of care across settings. Their work over the past decade has illuminated much about the gaps in the transitional care processes, recommended strategies for improvement, and provided a framework for structuring and evaluating communication processes across the health care continuum. 2 They state that communication between providers about patients is fundamental to continuity. In this article, Anderson and Helms provide empirically based evidence about the dynamics of patient care communication. Valuable information about the types and amount of data most often communicated and the organizational and patient characteristics that affect communication are discussed. While identifying the key issues that affect communication during transitional care, the authors discuss the effect on continuity of care and encourage the reader to develop institution-specific strategies to overcome these challenges.
Building on the work by Anderson and Helms, the article by Bowles reports on the results of an evaluation using the Omaha System as a communication tool across settings. The study results provide a description of the types and frequencies of patient problems identified and the nursing interventions documented by staff and APNs during hospitalization of elderly patients admitted with six different cardiac diagnoses. The Omaha System is one of the standardized languages recognized by the American Nurses Association for describing nursing care. The ability to name, describe, organize, and quantify the work of nurses has important implications for communication across settings by standardizing the way patient's needs are described and enabling a summarization of the major interventions achieved in a particular care setting. The continuing themes throughout this issue of adequate continuity of care, positive patient outcomes, and patient satisfaction are all dependent on the ability to effectively communicate the status of patient's problems, how they were or are to be treated, and whether they were resolved or remain. The Omaha System has been used in home health and other community settings for more than 25 years. As suggested in this study, it may be an effective mechanism for improving communication and continuity of care between the hospital and home care.
The uniqueness of each patient condition and the plethora of medical treatments result in great variation in the transitional care needs of specific patients. Patients who receive (internal) cardioverter defibrillators (ICDs) are a growing and unique subset of patients who require variation from the usual discharge protocols. White expands the knowledge on the specific details of transitional care for patients with an ICD. Her holistic approach to management includes much practical and relevant information that includes the preoperative preparation and acute and transitional care of the patient with an ICD.
Transitional care by nurse experts comes to life through case studies written by APNs Bixby, Konick-McMahon, and McKenna who actively care for patients in an ongoing clinical trial headed by Naylor. The complex and challenging situations in which elders with heart failure live and cope are described, and the creative interventions provided by the APNs are shared. This article takes the reader on a journey experienced by three patients as they face social, emotional, and economic challenges in addition to the demands of living with heart failure. The effect of this transitional care model is evident as these authors describe their expert practice. The successful avoidance of further hospitalizations in these patients is just one indicator of their success.
The final two articles in this issue focus on the immediate postdischarge period. Knoll and Johnson report on their qualitative study about the postsurgical experiences of family caregivers. Study findings reveal the influence of prior experience as a caregiver and the caregiver's and care receiver's outlooks on life, their relationships, and their expectations on the postdischarge experience. The reader gains insight into the thoughts and feelings of life as a caregiver and can use this information to formulate interventions to support the transition process. Caregivers reported feeling stressed, tired, vulnerable, and that their lives were on hold. They expressed the value of transitional care as they described how the continued care by a nurse in the home greatly helped to reinforce teaching, change behaviors, and provide reassurance. Caregivers also reported that having information on the recovery process and what to expect helped to make the experience less stressful and anxiety producing.
Bull, Hansen, and Gross reinforce the importance of preparation. Bull and colleagues reported that feeling prepared to manage care after hospitalization was a significant predictor of satisfaction with discharge planning. The recognition of what patients and caregivers' need after discharge is a significant challenge in transitional care. In addition, continuity of care is also extremely important and was the second predictor of satisfaction with discharge planning. These two factors, adequate preparation and continuity of care, are vital components of ideal transitional care.
The value of successful transitional care and the complexity of implementing ideal models have been demonstrated throughout this issue of The Journal of Cardiovascular Nursing. Providers of transitional care face many challenges. I hope this issue contains useful information to help you to improve the transitional care of all patients.
-Kathryn H. Bowles, PhD, RN
Research Assistant Professor; School of Nursing; University of Pennsylvania; Philadelphia, Pennsylvania; Issue Editor
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