Transitional Care Partners: A hospital-to-home support for older adults and their caregivers
Article first published online: 26 NOV 2012
©2012 The Author(s) ©2012 American Association of Nurse Practitioners
Journal of the American Association of Nurse Practitioners
Volume 25, Issue 8, pages 407–414, August 2013
How to Cite
Hendrix, C., Tepfer, S., Forest, S., Ziegler, K., Fox, V., Stein, J., McConnell, E. S., Hastings, S. N., Schmader, K. and Colon-Emeric, C. (2013), Transitional Care Partners: A hospital-to-home support for older adults and their caregivers. American Assoc Nurse Prac, 25: 407–414. doi: 10.1111/j.1745-7599.2012.00803.x
- Issue published online: 24 JUL 2013
- Article first published online: 26 NOV 2012
- Manuscript Accepted: AUG 2011
- Manuscript Received: MAR 2011
- Veterans Health Affairs, Office of the Geriatrics and Extended Care as part of its Transformation-21 Initiative
- nurse practitioners;
- home care;
- veterans' health;
- transitional care model
To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans.
Hospital records of TLC patients to track their hospital and emergency department visits before and after the TLC Partners enrollment. Caregivers of patients completed Preparedness in Caregiving and the Short Form Zarit Burden Scale during the first week of the TLC Partners enrollment and on the week when the services ended.
The proportion of patients with one or more emergency department visits and rehospitalization is consistently lower among TLC patients compared to non-TLC patients at 30 and 60 days of hospital discharge. The mean preparedness and burden scores before and after the program essentially remained the same.
Implications for practice
The description of the implementation of the TLC Partners offers an example of how nurse practitioner-led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models.