Transitional Care of Older Adults Hospitalized With Term Paper

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Transitional Care of Older Adults Hospitalized with Heart Failure Experiment

Naylor, M.D., Brooten, D., Campbell, R.L., Maislan, G.,, McCauley, K.M. Schuartz, J. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized Trial.

This article has an interesting approach to summarizing the experiment that was conducted. Instead of a formal abstract, the article instead summarizes the design and outline in several sections. These sections include objectives, design, setting, participants, intervention, measurements, results, and conclusions. The sections that are listed replace the standard format for an abstract that condenses the design and the findings into one formal section. Personally, I prefer the organization of this format better as it more clearly illustrates all of the factors in the research in a clear and easily identifiable format.

Analysis of the Introduction

The authors of this research do state the problem that they are researching in a clear and coherent manner. The specific problem relates to older adults and their vulnerability during a transition from a care facility to a home setting. During this transitional state, it has been identified that many preventable poor discharge outcomes occur. Individual factors contributing to negative outcomes include multiple comorbid conditions, functional deficits, cognitive impairment, emotional problems, and poor general health behaviors; system factors associated with poor outcomes include breakdowns in communication between providers and across healthcare agencies, inadequate patient and caregiver education, poor continuity of care, and limited access to services (Naylor, et al., 2004). Furthermore, it is estimated that roughly one third of all patients and caregivers report substantial unmet needs among this transitional population.

The problem this then framed in a more specific manner that includes a specific segment and the costs that this segment at to the healthcare systems expenditures. The breakdown in care and/or communication that this specific segment incurs is responsible for healthcare costs annually in the billions. The specific segment that is mentioned is the elder group that experiences a form of heart failure. This group is responsible for the highest hospitalization rate of all demographics and these patients typically have multiple comorbid medical conditions, numerous disabling symptoms, complex medication regimens, and limited self-management skills (Naylor, et al., 2004). The authors also note that little is known about the effectiveness of care management strategies for elders experiencing an acute episode of heart failure complicated by multiple other chronic health conditions

In my opinion the author clearly states the problem being investigated and introduces the problem with relative promptness. Hence the background is well-developed and adequate to support the background information needed to introduce the study and its place in the research and the literature regarding the subject. The importance of the study is clearly illustrated by demographical information as well as its financial implications. Furthermore, the study introduces the effectiveness of interventions based on other studies that have been conducted that have offered significant results. In particular, in my opinion, this is a valuable contribution to the article because it emphases the potential that research in this area can have on patient outcomes in this group.

The specific objective of this randomized control trial (RCT) RCTwas to examine the sustained effect of a 3-month comprehensive transitional care (discharge planning and home follow-up) intervention directed by advanced practice nurses (APNs) for elders hospitalized with heart failure on time to first readmission or death, total rehospitalizations, readmissions due to heart failure and comorbid conditions, quality of life, functional status, patient satisfaction, and medical costs. This study presents, on a spectrum of clinical and economic outcomes, the first multisite assessment of a transitional care intervention targeting the comprehensive set of serious health problems and risk factors common in elders throughout an acute episode of heart failure (Naylor, et al., 2004).

The scope of the study is well designed and provides enough background to introduce the problem in a clear and coherent manner that includes both theoretical and operational factors. The hypothesis is not as elaborate as the rest of the background. However, it seems to cover the research intention fairly well by simply stating that "given the established association between breakdowns in care during the transition from hospital to home and poor postdischarge outcomes, such an intervention needs to continue through the postdischarge period to assure longerterm improvements in patient and caregiver outcomes (Naylor, et al., 2004)." Although the hypothesis mentions an improvement in outcomes, it does not however give any quantitative estimate as to how much of an improvement could stand to be made by an intervention.

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Analysis of Research Methods

The research design was a randomized control trial that utilized an academic community and community hospital network in the Philadelphia area. The sample consisted of patients in the same region that were all aged sixty five and older who had a diagnosis of heart failure. Participants in the study had to speak English and be alert and responsive enough to communicate with the authors and their team on a regular basis. The number of participants was somewhat limited by the study mentioned that the number was consistent with other RCT experiments in the same niche. The control group received basically the same level of care that they would have normally received based on the standards of the current healthcare network. However, in the intervention group received specialized care that was designed with a range of comprehensive opinions based on various aspects of the patients care.

The intervention included all of the following components: (1) a standardized orientation and training program guided by a multidisciplinary team of heart failure experts (composed of a geropsychiatric clinical nurse specialist, pharmacist, nutritionist, social worker, physical therapist, and board-certified cardiologist specializing in the treatment of heart failure) to prepare APNs to address the unique needs of older adults and their caregivers throughout an acute episode of heart failure; (2) use of care management strategies foundational to the Quality-Cost Model of APN Transitional Care including identification of patients' and caregivers' goals, individualized plans of care developed and implemented by APNs in collaboration with patients' physicians, educational and behavioral strategies to address patients' and caregivers' learning needs, continuity of care and care coordination across settings, and the use of expert nurses to deliver and manage clinical services to high risk patient groups; and APN implementation of an evidence-based protocol, guided by national heart failure guidelines and designed specifically for this patient group and their caregivers with a unique focus on comprehensive management of needs and therapies associated with an acute episode of heart failure complicated by multiple comorbid conditions (Naylor, et al., 2004). Obviously, the intervention group received a substantially higher level of care than the control group.

RAs that were blind to the studies aims were used to collect data on regular intervals from both groups. The Kaplan-Meir survival estimates of the conditional survival probabilities into the computation of average cost per patient. This provided the basis for the financial computations that analyzed the economic estimates in the results section. This scale, although it provides the data necessary for analysis, seems to use a lot of assumptions to generate the data that may not accurately reflect the actual details of the patient's health and the costs associated with their healthcare. On the other hand, all models are subject to some liberties and are essential to preparing data for analysis. Therefore, even though such models may not be perfect, they do provide the necessary framework to investigate the hypothesis and are essential to progressing the knowledge base in healthcare.

Data on number of, timing of, and reasons for hospital readmissions, unscheduled acute care visits, and care provided by visiting nurses or APNs and other healthcare personnel were abstracted from patients' records and bills requested by the project manager via telephone calls and letters to physicians, hospitals, and home care agencies; all records from physicians' offices and records from remote hospitals and home care agencies were copied and mailed or sent by facsimile to the research offices at the University of Pennsylvania (Naylor, et al., 2004). Although this seems like an reasonable and objective method to collecting data there is little mention of the specific practices that were used to collect this data.

Results Analysis

The authors state that the Intervention and control groups were similar in all baseline sociodemographic characteristics, with the exception of hypertension, there were no statistically significant differences, and overall the groups appeared clinically similar (Naylor, et al., 2004). Additionally, twenty-four patients (10%) had died by 52 weeks postdischarge (13 control vs. 11 intervention, P5.830). The study broke the factors up based on a demographic comparison, rehospitalization, mortality, and a quality of life statistical comparison. The authors also conducted a standard deviation analysis of the patient satisfaction scores as well and most of this information is provided in corresponding tables. It appears that the likelihood of either type I or II errors are relatively low. There are many figures that appear in the tables that do not appear to be mentioned in the text. However,.....

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