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Transitional Care Partners: A hospital-to-home support for older adults and their caregivers

Authors

  • Cristina Hendrix DNS, GNP-BC,

    (Nurse Investigator), Corresponding author
    1. Duke University School of Nursing, Durham, North Carolina
    2. Duke University Center for the Study of Aging and Human Development, Durham, North Carolina
    • Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
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  • Sara Tepfer MSW, LCSW,

    (Social Worker)
    1. Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
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  • Sabrina Forest DNP, ANP-BC,

    (Nurse Practitioner)
    1. Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina
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  • Karen Ziegler MSN, ANP-BC (Nurse Practitioner),

    1. Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina
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  • Valerie Fox MS, OTR/L,

    (Occupational Therapist)
    1. Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina
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  • Jeannette Stein MD,

    (Physician)
    1. Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina
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  • Eleanor S. McConnell PhD, GCNS,

    (Nurse Investigator)
    1. Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
    2. Duke University School of Nursing, Durham, North Carolina
    3. Duke University Center for the Study of Aging and Human Development, Durham, North Carolina
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  • Susan Nicole Hastings MD,

    (Physician)
    1. Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
    2. Duke University Center for the Study of Aging and Human Development, Durham, North Carolina
    3. Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina
    4. Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
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  • Kenneth Schmader MD,

    (Physician)
    1. Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
    2. Duke University Center for the Study of Aging and Human Development, Durham, North Carolina
    3. Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
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  • Cathleen Colon-Emeric MD

    (Physician)s
    1. Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
    2. Duke University Center for the Study of Aging and Human Development, Durham, North Carolina
    3. Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
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Correspondence Cristina Hendrix, DNS, GNP-BC, DUMC 3322, Durham, NC 27710. Tel: 919-684-9358; Fax: 919-681-8899; E-mail: Cristina.hendrix@duke.edu, cristina.hendrix@va.gov

Abstract

Purpose

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.

Data sources

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.

Conclusions

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.

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