Implementing a Transitional Care Program for High-Risk Heart Failure Patients: Findings from a Community-Based Partnership Between a Certified Home Healthcare Agency and Regional Hospital
Article first published online: 18 NOV 2011
© 2011 National Association for Healthcare Quality
Journal for Healthcare Quality
Volume 33, Issue 6, pages 17–24, November 2011
How to Cite
Russell, D., Rosati, R. J., Sobolewski, S., Marren, J. and Rosenfeld, P. (2011), Implementing a Transitional Care Program for High-Risk Heart Failure Patients: Findings from a Community-Based Partnership Between a Certified Home Healthcare Agency and Regional Hospital. Journal for Healthcare Quality, 33: 17–24. doi: 10.1111/j.1945-1474.2011.00167.x
- Issue published online: 18 NOV 2011
- Article first published online: 18 NOV 2011
- AARP Public Policy Institute. (2010). Health reform initiatives to improve care coordination and transitional care for chronic conditions. Retrieved on December 6, 2010, from www.aarp.org/ppi.
- Agency for Healthcare Research & Quality. (2007). Facts and figures 2007: Healthcare cost and utilization project. Retrieved on December 8, 2010, from www.hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_1.jsp.
- 2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51, 549–555. (
- 2004). Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 140, 533–536. , & (
- 2010). Improving care transitions: A key component of health reform. Retrieved December 6, 2010, from healthaffairs.org/blog/2010/04/29/improving-care-transitions-a-key-component-of-health-reform/. , & (
- 2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556–557. , & (
- 2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166, 1822–1828. , , , & (
- 2010). A hybrid transitional care program. Critical Pathways in Cardiology, 9, 231–234. (
- 2010). Improving heart failure in home care with chronic disease management and telemonitoring. Home Healthcare Nurse, 28, 606–617. , & (
- 1997). Factors contributing to rehospitalization of elderly patients with heart failure. Journal of Cardiovascular Nursing, 11, 75–84. , , & (
- 2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418–1428. , , & (
- 2006). Readmission of patients with congestive heart failure: The need for focused care. Asian Journal of Gerontology & Geriatrics, 1, 59–60. , , & (
- 2009). Complexity in geriatric home care. Journal for Healthcare Quality, 31, 34–43. , , , , & (
- 2006). Transitional care: A critical dimension of the home healthcare quality agenda. Journal for Healthcare Quality, 28, 20–28. (
- 2004). Transitional care of older adults hospitalized with heart failure: A randomized controlled trial. Journal of the American Geriatrics Society, 52, 675–684. , , , , , & (
- 2010). Scaling up: Bringing the transitional care model into the mainstream. New York, NY: The Commonwealth Fund, Issue Brief, 103, 1–11. , & (
- RAND Health COMPARE. (2010). Hospital pay for performance. Retrieved December 21, 2010, from www.randcompare.org.
- 2007). Development and testing of an analytic model to identify home healthcare patients at risk for hospitalization within the first 60 days of care. Home Health Care Services Quarterly, 26, 21–36. , & (
- 2005). The crucial role of patient education in heart failure. The European Journal of Heart Failure, 7, 363–369. (
- U.S. Department of Health and Human Services. (2010). Hospital readmissions measures. Retrieved December 22, 2010, from www.hospitalcompare.hhs.gov/staticpages/for-consumers/ooc/readmission-measures.aspx.
- 1990). Early readmission of elderly patients with congestive heart failure. Journal of the American Geriatrics Society, 38, 1290–1295. , , , , & (