The Visiting Nurse Service of New York Transitional Care ... · The Visiting Nurse Service of New York Transitional Care Collaborative Joan Marren, RN, MEd Robert J. Rosati, PhD

Medicare Readmissions SummitWashington, DC June 2010

The Visiting Nurse Service of New York Transitional Care Collaborative

Joan Marren, RN, MEdRobert J. Rosati, PhD

June 8, 2010, 11:15 – 11:45


OverviewOverview

•• Background on VNSNYBackground on VNSNY

•• Our Experience with Our Experience with RehospitalizationRehospitalization–– TrendsTrends–– Patient CharacteristicsPatient Characteristics–– Risk ModelRisk Model

•• Internal Initiatives to Reduce HospitalizationInternal Initiatives to Reduce Hospitalization

•• Cross Setting InitiativesCross Setting Initiatives

•• Wrap up and QuestionsWrap up and Questions


Visiting Nurse Service of New York


Visiting Nurse Service of New York

• Founded in 1893 by Lillian D. Wald, VNSNY is the largest non-profit home health care agency in the U.S.

• Serves all five boroughs of NYC, plus Westchester and Nassau Counties

• Provides a range of services to an average daily census of 30,000 cases, from newborns to seniors

• 14,000 employees

• Complex patient population

The “Henry Street Family” (c. 1900)

Visiting nurses (date unknown)


About the NYC Environment

• 120 Hospitals; 6 Academic Medical Centers; >22,000 physicians

• High hospital utilization compared to nation

• Many residents lack a “medical home” due to high specialist penetration, driving higher us of ED and urgent care centers for primary care.


2009 State Scorecard on Health System Performance: Bottom Quartile

MichiganMichiganNew YorkDistrict of ColumbiaDistrict of ColumbiaNew JerseyNew JerseyWest VirginiaWest VirginiaTennesseeTennessee

Source: Commonwealth Fund State Scorecard on Health System Performance

IllinoisIllinois

KentuckyKentucky

TexasTexas

ArkansasArkansas

LouisianaLouisiana

OklahomaOklahoma

MississippiMississippi


Medicare Beneficiaries

•• 20% of Medicare beneficiaries rehospitalized in 20% of Medicare beneficiaries rehospitalized in 30 days30 days

•• 35% of Medicare beneficiaries rehospitalized in 35% of Medicare beneficiaries rehospitalized in 90 days90 days

• Source: SF Jencks. Re hospitalizations Medicare FFS. NEJM. Apr 2 2009 360(14)1418


VNSNY Overall Hospitalization RateVNSNY Overall Hospitalization Rate Acute Care ProgramAcute Care Program


VNSNY Overall Hospitalization Rate by Diagnosis


Patient Characteristics

No Event of Hospitalization (N=36,984)

Had an Event of Hospitalization within

First 60 Days (N=9,175)

P-Value

AgeAge (mean) 70.31 71.01 0.0002

GenderFemale (%) 64.3% 60.8% <.0001

RaceWhite (%) 50.7% 45.9% <.0001Hispanic (%) 20.5% 23.4% <.0001

PayerMedicare FFS (%) 39.3% 40.1% 0.2007Medicaid FFS (%) 8.8% 10.9% <.0001Dually Eligible (%) 19.5% 24.2% <.0001Medicare HMO (%) 9.0% 8.0% 0.004Medicaid HMO (%) 5.4% 4.6% 0.0018Private Insurance HMO (%) 15.1% 10.5% <.0001Other (%) 1.0% 0.3% <.0001No Charge (%) 1.8% 1.4% 0.0097

Rosati, R., & Huang, L. (2007)





First 60 Days (N=9,175)P-Value

EducationHigher then Graduate (%) 4.9% 4.2% 0.0024

Living ArrangementAlone (%) 33.9% 31.7% 0.0001

Previous Case HistoryHad Previous Cases Prior 6 Months (%) 21.1% 32.2% <.0001# of Hospitalization Prior 6 Months 0.7741 0.9728 <.0001Had Hospitalization Prior 30 Days (%) 72.5% 78.8% <.0001

General Health StatusPoor Prognosis (%) 9.0% 17.1% <.0001Rehab Guarded (%) 21.8% 33.2% <.0001Life Expectancy <=6 Months (%) 2.0% 4.2% <.0001

Certified Visits By PhysiciansNursing (mean) 27.49 31.66 <.0001HHA (mean) 17.22 22.32 <.0001Social Work (mean) 1.09 1.62 <.0001






First 60 Days (N=9,175)P-Value

Diabetes (%) 17.6% 22.2% <.0001Hypertension (%) 13.2% 10.9% <.0001CHF(%) 5.9% 9.7% <.0001Ischemic Heart Disease (%) 5.4% 5.3% 0.8138COPD (%) 3.4% 5.0% <.0001Cardiac Dysrhythmias (%) 4.0% 4.5% 0.0312HIV (%) 1.5% 2.6% <.0001CVA (%) 0.5% 0.5% 0.9903



Risk Model

• A Logistic regression analysis was performed to predict the likelihood of hospitalization within the first 60 days of admission

• Empirically tested and clinically validated

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Levels of Risk

LOW: Very Low: [0.000, 0.043 ] Low: [0.430, 0.079 ]Low Moderate: [0.079, 0.124 ]

MODERATE: Moderate: [0.124, 0.211]Moderate High: [0.211, 0.357]

HIGH: High: [0.357, 0.442]Very High: [0.442, 1.000]

Probability of Hospitalization



Risk Stratification and Potential Demand for Transitional Care

Risk Levels based on Predictive Model

Example


Communicating Risk Levels to Clinicians

Example


Transitional Care at VNSNY


What is Transitional Care?What is Transitional Care?

““A set of actions designed to ensure A set of actions designed to ensure the coordination and continuity of the coordination and continuity of health care as patients transfer health care as patients transfer between different locations or between different locations or different levels of care within the different levels of care within the same location.same location.””

Eric Coleman, MDEric Coleman, MDSource: Coleman EA, Boult CE Improving the Quality of Transitional Care for Persons with Complex

Care Needs.

Journal of the American Geriatrics Society. 2003;51(4):556-557

http://www.caretransitions.org/documents/Improving%20the%20quality%20-%20JAGS.pdf

http://www.caretransitions.org/documents/Improving%20the%20quality%20-%20JAGS.pdf


VNSNY Transitional Care Learning Collaborative

• Developed bundle of interventions (guides and tools) to be integrated at every care level, including risk assessment and frontloading patient contacts (nurse visits and phone calls)

• Spread strategy for all staff to be trained in Transitional Care Standards, Protocols and Tools

• Established Transitional Care as ‘Core Competency’ for all staff


Moving from Best Practices to Standards and Protocols

20

Self-Management Medication Reconciliation Patient Risk & Planned Care


Transitional Care ToolsTransitional Care Tools

• My Action Plan

• Self Management Support (goal setting)

• My Medication Record

• Telephone Care Management

• SBAR Communication


Rapid Response to Decline in the HomeRapid Response to Decline in the Home ‘‘My Action PlanMy Action Plan’’

Your Team’s Number is:

“My Action Plan” Call your nurse or physician any time your medical condition changes. A nurse is on call 24 hours a day, including nights, weekends and holidays.

General Problems • No bowel movement in 3 days • New skin problems • Change in balance, coordination, strength • Change in mental status or behavior • Pain medication is not effective • Nausea or vomiting • Running out of medication • Fall • Dizziness • Diarrhea • Fever

Urinary Problems • Foul odor to urine • Catheter not draining • Back or flank pain • Unable to urinate • Bloody or cloudy urine • Change in urine color • Body aches

Signs of wound infection • Increased redness • More or different drainage • Wound or area is more painful • Temperature of 100 or more • New odor from a wound • Temperature is outside my target of

_______.

Diabetic Problems

• Sudden weakness • Uncontrollable thirst • Sudden dizziness • Increased urination • Sweating spells • Uncontrollable hunger • Frequent headaches • Itching • Drowsiness • Blood sugar level greater than ________

or less than ________.

Heart/Lung Problems • Productive or frothy cough • New congestion • Increased shortness of breath • Increased swelling in legs or feet • Increased weakness • Weight gain of 3 or more pounds in 1 day

or 5 or more pounds in one week. My current weight is ________.

• Blood pressure above my target blood pressure of ________.

• Heart rate is outside my target heart range of ________.

• Oxygen saturation level is outside target of ________.

If you take Coumadin • Bleeding from nose, gums, rectum • Bruising • Tarry stools • Falls

Call 911 if you (have):

• Fall and are bleeding. • Fall and have a broken bone. • Severe or prolonged bleeding. • Severe or prolonged pain. • Are unable to wake the patient.

• New onset of slurred speech. • Sudden weakness in arms or legs. • Chest pain that medication does not help. • Increased difficulty breathing not relieved

by rest or medications.


Cross Setting Transitional Care

VNSNY & Hospital Partner InitiativesVNSNY & Hospital Partner Initiatives

Initiative Partner FocusHeart Failure Transitions Program.

NY Hospital Queens, Bellevue and New York University Medical Center.

Reduce avoidable hospitalizations among patients with Heart Failure within 30 days.

E.R. Transitions Program. Mount Sinai Hospital, New York Presbyterian Hospital.

Avert potential admissions or, if admitted, then flag patient for referral to home care and early discharge.

Transitional Care Nurse Practitioner

Mount Sinai Hospital NP integrates care across continuum and serves as transitional PCP until 1st

MD appointment.

UHF Transitional Care Collaborative

Maimonides / Lutheran, NYU, Beth Israel Hospitals.

Improve caregiver / patient experience during in care during transitions.


Highlight Highlight –– The VNSNY/ Mount Sinai The VNSNY/ Mount Sinai Transitional Care NP InitiativeTransitional Care NP Initiative

Visiting Nurse Service of New YorkHospitalization Rate : 29.8%

Mt Sinai Medical Center High Referral and

Hospitalization Rate 30.6%

Mt Sinai Hospital Discharges followed by Internal Medicine (IMA)

(avg monthly census – 120)

Referred to 2 VNSNY Teams

Manhattan Region Home CareHospitalization Rate : 31.0%

Target PopulationTarget Population

Teams 21 and 06 (East Harlem)Hospitalization Rate : 35.5%


Implementation PhasesImplementation Phases

•• Phase One : NP Role as Cross Setting Phase One : NP Role as Cross Setting Integrator & Transitions ConsultantIntegrator & Transitions Consultant

•• Phase Two : Phase Two : VNSNY Teams Implement Transitional Care Standards & Add a Home Care Coordinator in ED

•• Phase Three : NP as Cross Setting Phase Three : NP as Cross Setting Integrator & Transitional Primary Care Integrator & Transitional Primary Care Provider Provider


Phase I Phase I –– 2004 to 20072004 to 2007

Transitional Care Description Insights

Phase IPlanning(2004 Planning)

Testing2005-07

Tested model using home care NP as “integrator”. Focused on rapid response to condition decline & improving PCP communication.

Developed risk assessment at start of home care (predictive model).

Reduced 30 day rehospitalizations ofIMA patients on VNSNY teams (avg. monthly census 125)

Reduced time to 1st medical appointment post discharge to within 2 weeks (vs. 30 days).

Regular cross setting improvement team meetings were held and were critical (Hosp, IMA, VNSNY)

Results not sustainable without coordinated interventions across all settings.

Data tracking – not sustainable. Need to share data sources.

ED may provide higher leverage for earlier assessment and intervention.


Transitional Care NP RoleTransitional Care NP Role

Phase One: Phase One: 52 high risk patient home visits by NP 52 high risk patient home visits by NP , discharged , discharged from Mt Sinai Hospital followed by IMA physicianfrom Mt Sinai Hospital followed by IMA physician

–– Diabetes primary diagnosis. Average age 68 Diabetes primary diagnosis. Average age 68 –– 39 resulted in same day NP med and/or treatment 39 resulted in same day NP med and/or treatment

change . (Avg. # of meds 8 change . (Avg. # of meds 8 –– 15)15)–– 20 patients 20 patients –– wrong MD identifiedwrong MD identified–– 27 treatment plans signed by PCP within 30 days27 treatment plans signed by PCP within 30 days


Reduce HospitalizationsReduce Hospitalizations Mt Sinai Internal Medicine and VSNNY Mt Sinai Internal Medicine and VSNNY

% of Hospitalization by Active censusUnadjusted IMA patients

15.1%14.7%14.4%

11.9%10.9%

10.3%9.2%

8.1%9.7%

11.2%11.0%

8.7%7.6%

10.2%

8.1% 7.6%

3.9%

5.7%6.8%

9.7%

6.4% 6.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Phase I Pilot Tracking: Manual

Transitional Care NP : medical managementFirst Medical Appointment in 2 Weeks Home Care Team Transitional Care Interventions

•Frontloading Visits and Phone Calls•Medication Reconciliation•Self Management Support

Transitional Care NP : medical managementFirst Medical Appointment in 2 Weeks Home Care Team Transitional Care Interventions

•Frontloading Visits and Phone Calls•Medication Reconciliation•Self Management Support


Number of Days to 1Number of Days to 1stst Medical Appointment Post D/CMedical Appointment Post D/C

"Average # of days to first IMA primary care appointment after discharge from hospital"

30

22 2023

2624

29

19 21 20 20 2218

0

5

10

15

20

25

30

35

Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06

Avg

# o

f Day

s

Phase I Pilot Tracking: Manual


Phase II Phase II -- 20082008

Transitional Care Description Insights

Phase II(2008)

Home Care Coordinator (RN) in ED –12% of patients evaluated were discharged home.

Embedded screening tool in EHR.

Developed home care team competencies in transitional care.

2% reduction in Mt Sinai hospitalization rate for home care patients.

Patients not eligible for home care could benefit from brief NP transitional care.

Data tracking – not sustainable. Need to share data sources.

NP skills could add value to ED interventions.

ED staff supportive of model. Improves quality of care.


Phase III Phase III -- CurrentCurrent

•• NP provides transitional primary care as enhancement NP provides transitional primary care as enhancement to 30to 30--90 day home care episode for 90 day home care episode for ‘‘at riskat risk’’ patients patients from the time of discharge until the first follow up from the time of discharge until the first follow up appointment with primary care provider. appointment with primary care provider.

•• ““NP onlyNP only”” provides transitional primary care and other provides transitional primary care and other coaching/support services for at risk patients from coaching/support services for at risk patients from discharge until first follow up appointment discharge until first follow up appointment

•• VNSNY Home Care Consultant (RN) assigned to the VNSNY Home Care Consultant (RN) assigned to the Mount Sinai Medical Center ED assesses for and Mount Sinai Medical Center ED assesses for and coordinates transitional home care with NP.coordinates transitional home care with NP.


Specific AimsSpecific Aims

• Reduce 30 day re-hospitalization of Mt Sinai patients and patients mutually served by VNSNY and MSH

• Reduce average number of days to 1st medical appointment post hospital discharge.

• Increase the number of patients assessed for high risk for re-hospitalization at:

– Hospital admission (opportunity)– Hospital discharge (current project)– Admission to Home care (predictive model- current project)– Primary care risk assessment (opportunity)


Patients Livingin EastHarlem

Mt Sinai

Emergency Room

VNSNYNew Team Standards Transitional Care “at risk”

Complexity of Transitional Care Coordination Complexity of Transitional Care Coordination –– Defining Processes Roles, Technology IntegrationDefining Processes Roles, Technology Integration within and across settingswithin and across settings

Mt Sinai Hospital

Triple AimPopulation Health Care ExperienceCost/Capita

Triple AimPopulation Health Care ExperienceCost/Capita

VNSNYProfessional Corporation

NP Only - Brief

“at risk”

Mt Sinai Internal Medicine Associates


Phase IIIPhase III Defining Processes and Roles Across SettingsDefining Processes and Roles Across Settings

N P T ra n s it io n a l C a re M o d e l

PS

MP

MD

Hos

pita

l MD

and

HC

CN

urse

Pra

ctiti

oner

ED

NP

and

HC

CC

OC

Pat

ient

P t a d m it te d toh o s p ita l

M D - Id e n t ify fo rre fe rra l toh o m e c a re

D a ily R e v ie w s o fr is k s c o re s , M S H

a n d V N Sa d m is io n s a n d

IR O C

P a tie n t d is c h a rg e dfro m h o s p ita l

M D - C o m p le teM e d ic a t io n

R e c o n c ila t io n(J C A H O )

H C C - E v a lu a teu s u a l a n d T C

p a tie n ts

E v a lu a te p t inh o s p ita l

D e v e lo p N PT ra n s it io n /S x

m g m t p la n

D e v e lo p H C CD is c h a rg e P la n

w ith S W , M D a n dN P

C o m m u n ic a te sT ra n s it io n /S x

m g m t p la n

M e d ic a t io nR e c o n c ilia t io n a n d

R a p id R e s p o n s e a sn e e d e d

R e v ie w s N PT ra n s it io n /S x

m g m t p la n a n dH C C D /C p la n

S O C a n dim p le m e n ta t io n o f

T ra n s it io n /S x m g m tp la n

P a t ie n t h o m e

P a tie n t D /C d f ro mV N S to o th e r

p ro g ra m o r o n ly toP M D /s p e c ia lis ts

D is c h a rg e p ro c e s s

D is c h a rg ep ro c e s s w /T ra n s it io nP la n to o lfo r P M D

R e v ie w s N PT ra n s it io n /S x

m g m t p la n a n dH C C D /C p la n fo r

n e w a n d IR O C

D a ily re v ie w o f r is ks c o re s a n d

h o s p ita liz a t io n s

M D - C o m m u n ic a te s w ithN P , S W , H C C o n

T ra n s it io n P la n a n d D /Cp la n

S ig n s S O C o rd e rs

H C C - R e le a s ec a s e to f ie ld te a m

N P d is c h a rg ep ro c e s s w /

T ra n s it io n /S xm g m t p la n fo r

o th e r V N Sp ro g ra m /P M D

R e v ie w sT ra n s it io n /S x

m g m t p la n w ith N Pa n d C O C

R e c e iv e T ra n s it io nP la n to o l f ro m

V N S

A s s is ts in D /Cp ro c e s s

E v a lu a te p ts w /p a s s in g e v a l

c r ite r ia

N P - D e c is io n tos e n d h o m e w ithH C o r to a d m it

H C C -im p le m e n ta t io n o f

H C p la n

N P /H C C -jo in t v is itso n 1 ) E D p a t ie n ts

a d m it te d a n d 2 )a d m it te d p a t ie n tsre fe rre d fro m u n it

N P /H C Cd e v e lo p m e n t o f

s y m p to mm a n a g e m e n t p la n

fo r d /c

H C C re le a s e sc a s e

Hospitalist RoleHospital Risk AssessmentsHospital Discharge Planning

with SW/CM support, referral to HC

And TC

Hospitalist RoleHospital Risk AssessmentsHospital Discharge Planning

withSW/CM support, referral to HC

And TC

Home Health TeamTransitional Home Care

Standards

Home Health TeamTransitional Home Care

Standards

First Medical Appointment within 1 week of discharge . PCP, Hospitalist, NP communication.

NP as ‘

Interim PCP ‘NP as ‘

Interim PCP ‘


Collaborative Agreement and Credentialing Collaborative Agreement and Credentialing VNSNY and Mount Sinai HospitalVNSNY and Mount Sinai Hospital

•• Collaborative practice agreement with HospitalistCollaborative practice agreement with Hospitalist

•• Hospital Department of Nursing Education oversees Hospital Department of Nursing Education oversees credentialing process and orientationcredentialing process and orientation

•• Customized scope of practice according to practice area.Customized scope of practice according to practice area.–– write treatment orders in the homewrite treatment orders in the home–– modify and individualize medication regimenmodify and individualize medication regimen–– Respond to changes in conditionRespond to changes in condition

•• Access to hospital databasesAccess to hospital databases


Phase III Phase III -- Target PopulationTarget Population Risk for Readmission within 30 daysRisk for Readmission within 30 days

• Any ER visit in last 30 Days and/or 2 or more hospitalizations in 6 months

• Six or more medications• More than 2 co-morbidities• Living alone / no involved caregiver• Requiring assistance in one or more ADLs• Documented history of non-adherence• Mental or Emotional condition / Confusion / Dementia


Pt discharged To home

with TC intervention

Pt discharged To home

with TC intervention

NP visit within 48 hours

NP visit within 48 hours NP

InterventionsNP

Interventions

Pt has follow up appointment

With PCP/IMA

Pt has follow up appointment

With PCP/IMA

NP follows up with patientAnd IMA after visit to

Assess need for continuingTC Home intervention

NP follows up with patientAnd IMA after visit to

Assess need for continuingTC Home intervention

NoNo

Discharged from TCDischarged from TC

YesYes

NP post discharge High Level Workflow


NP Interventions

• Medication reconciliation• Change and adjust meds and treatment plan PRN• Document Inpatient and Outpatient Interventions • Collect and document metrics• Support follow up w/ PCP/IMA clinic• Coordinate with Home Care (if applicable), • Evaluate needs -

– PT/OT/SW/SLP– DME– Need for Home Care– Home Safety– Caregiver Support– Hospice/Palliative Care


Case Study

• 91 yo female living alone with no services admitted to hospital after syncopal episode

• Diagnosed With Stage 4 lung CA and PE• Home with PT and HHA eval and TC plan to

coordinate Palliative care and Hospice• Readmitted within 24 hours due to home

environment• New discharge disposition – referred to

Hospice


Case by Case Learning: Developing Reliable Processes and Standards to Close Transitional Care Gaps

Potential Drivers of Readmission:• Gaps-End of life/prognosis discussions• Gaps-Family discussions about goals of care• Gaps-Collaboration with PCP and medical

follow up plan• Delays in referral to Transitional Care NP (day

of discharge)• Gaps-Home Care team implementation of TC

standards, protocols


Lessons LearnedLessons Learned Structure, Leadership, ResourcesStructure, Leadership, Resources

•• Leadership Commitment Across SettingsLeadership Commitment Across Settings

•• Weekly/Monthly Cross Setting Improvement Weekly/Monthly Cross Setting Improvement Team Meetings Team Meetings

•• Quality and Measurement ResourcesQuality and Measurement Resources

•• ““Integrated DatabaseIntegrated Database””--all settings contribute to all settings contribute to measurement and monitoringmeasurement and monitoring


Lessons Learned Structure, Leadership, Resources

• NP Relationship building across settings

• Manual tracking – by NP – time consuming but important for learning , building model, evaluating

• Competing Incentives Across Settings

• Cost / Benefit


Thank You

Questions and Comments


ReferencesReferences

•• Coleman E, Perry C, Chalmers S, Min S (2006). The Care TransitioColeman E, Perry C, Chalmers S, Min S (2006). The Care Transitions Intervention: ns Intervention: Results of a Randomized Controlled Trial. Results of a Randomized Controlled Trial. Archives of Internal MedicineArchives of Internal Medicine 166166: 1822: 1822–– 1828.1828.

•• Forster A, Forster A, MurffMurff H, Peterson J, et al. The incidence and severity of adverse eveH, Peterson J, et al. The incidence and severity of adverse events nts affecting patients after discharge from the hospital. affecting patients after discharge from the hospital. Ann Intern MedAnn Intern Med.2003;138:161.2003;138:161-- 167.167.

•• Institute for Healthcare Improvement, 2007, Transforming Care aInstitute for Healthcare Improvement, 2007, Transforming Care at the Bedsidet the Bedside

•• HowHow--to Guide: Creating an Ideal Transition Home for Patients with Hto Guide: Creating an Ideal Transition Home for Patients with Heart Failureeart Failure

•• KonetzkaKonetzka R, R, SpectorSpector W, and W, and LimcangoLimcango M (2007). Reducing Hospitalizations from M (2007). Reducing Hospitalizations from Long Term Care Settings. Medical Care Research and Review OnlinLong Term Care Settings. Medical Care Research and Review Online as e as doi10.1177/1077558707307569. Accessed August, 2009.doi10.1177/1077558707307569. Accessed August, 2009.

•• Moore C, Moore C, WisniveskyWisnivesky J, Williams S, et al. Medical errors related to discontinuity oJ, Williams S, et al. Medical errors related to discontinuity of f care from an inpatient to an outpatient setting. care from an inpatient to an outpatient setting. J Gen J Gen IntInt MedMed. 2003;18:646. 2003;18:646--651.651.


ReferencesReferences

•• Naylor M. (2000) A Decade of Transitional Care Research with VulNaylor M. (2000) A Decade of Transitional Care Research with Vulnerable Elders. nerable Elders. The Journal of Cardiovascular Nursing. 14(3):1The Journal of Cardiovascular Nursing. 14(3):1--14.14.

•• Naylor M, et al (2004). Transitional Care of Older Adults HospitNaylor M, et al (2004). Transitional Care of Older Adults Hospitalized with Heart alized with Heart Failure: A Randomized, Controlled Trial. Journal of the AmericanFailure: A Randomized, Controlled Trial. Journal of the American Geriatrics Geriatrics Society. 52:675Society. 52:675--684.684.

•• Naylor M. Naylor M. Making the Bridge from Hospital to Home.Making the Bridge from Hospital to Home. The Commonwealth Fund; The Commonwealth Fund; Fall 2003.available at: Fall 2003.available at: http://www.commonwealthfund.org/spotlights/spotlights_show.htm?dhttp://www.commonwealthfund.org/spotlights/spotlights_show.htm?doc_id=225298oc_id=225298 . Accessed June 22 2007.. Accessed June 22 2007.

• Rosati, R., & Huang, L. (2007). Development and testing of an analytic model to identify home healthcare patients at risk for a hospitalization within the first 60 days of care. Home Health Care Services Quarterly , 26 (4), 21-36.

•• SchillingerSchillinger D, et al. Closing the loop: Physician communication with diabetD, et al. Closing the loop: Physician communication with diabetic ic patients who have low health literacy. patients who have low health literacy. Arch Intern MedArch Intern Med. 2003;163:83. 2003;163:83--90.90.

http://www.commonwealthfund.org/spotlights/spotlights_show.htm?doc_id=225298

http://www.commonwealthfund.org/spotlights/spotlights_show.htm?doc_id=225298

Documents

The Visiting Nurse Service of New York Transitional Care ... · The Visiting Nurse Service of New York Transitional Care Collaborative Joan Marren, RN, MEd Robert J. Rosati, PhD