Multiple chronic conditions among Medicare beneficiaries: State-level variations in prevalence, utilization, and cost, Low, L.
A systematic review of different models of home and community care services for older persons. McCauley, K. Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9 5 , Retireved from www. Chapter 3: Hospital inpatient and outpatient services. In Report to the Congress: Medicare payment policy pp. Retrieved from www. Morandi, A. Trabucchi, M. Predictors of rehospitalization among elderly patients admitted to a rehabilitation hospital: The role of polypharmacy, functional status, and length of stay.
Journal of the American Medical Directors Association, 14 10 , Transitions of care measures. Comprehensive discharge planning for the hospitalized elderly.
Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up
A randomized clinical trial. A decade of transitional care research with vulnerable elders. Journal of Cardiovascular Nursing, 14 3 , ; quiz Advancing high value transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36 2 , High-value transitional care: Translation of research into practice. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial.
JAMA, 7 , Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52 5 , Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 3 3 , Engaging older adults in their transitional care: what more needs to be done?
Journal of Comparative Effectiveness Research, 2 5 , Nicholas, J. Screening and preventive services for older adults. Nyweide, D.
Continuity of care and the risk of preventable hospitalization in older adults. Ottenbacher, K. Ostir, G. Hospital readmission in persons with stroke following postacute inpatient rehabilitation. Pham, H. Primary care physicians' links to other physicians through Medicare patients: The scope of care coordination.
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- Transient free surface flows in building drainage systems.
- 2018-12222 Scholar Projects?
Annals of Internal Medicine, 4 , Potvin, O. Anxiety, depression, and 1-year incident cognitive impairment in community-dwelling older adults. Journal of the American Geriatrics Society, 59 8 , Reeves, G. The association of comorbid diabetes mellitus and symptoms of depression with all-cause mortality and cardiac rehospitalization in patients with heart failure. Sand-Jecklin, K. Clinical Nursing Research, 23 6 , Selby, D. A single set of numerical cutpoints to define moderate and severe symptoms for the edmonton symptom assessment system.
Journal of Pain and Symptom Management, 39 2 , Shumway-Cook, A.
Maintenance of certification and licensing: What you need to know | MDedge Psychiatry
Physical Therapy, 80 9 , Sloan, J. Relationship between deficits in overall quality of life and non—small-cell lung cancer survival. Journal of Clinical Oncology, 30 13 , Spalding, M.
http://vtaras.com/141.php Geriatric screening and preventive care. American Family Physician, 78 2 , Steis, M. Screening for delirium using family caregivers: Convergent validity of the family confusion assessment method and interviewer-rated confusion assessment method. Jurnal of the American Geriatrics Society, 60 11 , Stevenson, L. Moving to a culture of safety in community home health care.
2017-2018 Scholar Projects
Tappenden, P. The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review. Health Technology Assessment, 16 20 , Toles, M. Transitions in care among older adults receiving long-term services and supports. Journal of Gerontological Nursing, 38 11 , Transitional care model.
Available: www. United Hospital Fund. What do family caregivers need? Vignaroli, E. The Edmonton symptom assessment system as a screening tool for depression and anxiety. Journal of Palliative Medicine, 9 2 , Vogeli, C. Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine, 22 0 , Wallston, K. Psychometric properties of the brief health literacy screen in clinical practice. Journal of General Internal Medicine, 29 1 , Ware, J.
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- Automatic Speech Recognition: A Deep Learning Approach;
- Introduction to Reconfigurable Computing: Architectures, Algorithms, and Applications.
- Understanding research.
- Psr assessment test.
A item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34 3 , How to score version 2 of the SF health survey. Yohannes, A. Reliability and validity of a single item measure of quality of life scale for adult patients with cystic fibrosis. Health Qual Life Outcomes, 9 , Zimmerman, M. Attiullah, N. Developing brief scales for use in clinical practice: The reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life.
Journal of Clinical Psychiatry, 67 10 , OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector. Find Out More Benefit for Members Members have access to current topic More Letter to the Editor Thank you for giving us the opportunity to respond to the letter to the editor written by Lisa Palucci. We are pleased to see her interest in older adults with multimorbidity and advancing models of care and care coordination for this growing population group. Continue Reading View all Letters Naylor, PhD, RN, FAAN Abstract Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness.
DOI: Vol20No03Man01 Key words: Transitional care, transitions, older adults, multiple chronic conditions, family caregivers, care experience, health outcomes, hospitalizations, resource use, care management, evidence-based practice Findings from multiple studies reinforce the poorly managed healthcare needs of older adults Staffing Uses APRNs who assume primary responsibility for care management throughout episodes of acute illness.
Engaging Patients and Caregivers Engages older adults in design and implementation of the plan of care aligned with their preferences, values and goals. Collaborating Promotes consensus on plan of care between older adults and members of the care team. Promoting Continuity Prevents breakdowns in care from hospital to home by having same clinician involved across these sites.
Fostering Coordination Promotes communication and connections between healthcare and community-based practitioners. Screening Identifying and targeting the specific population of older adults at risk for poor outcomes is the first essential component of the TCM. Staffing APRNs also maintain responsibility for day-to-day delivery of transitional care services, including oversight of other transitional care team members.
Maintaining Relationships A key feature of the TCM is establishing and maintaining trusting relationships with patients and family caregivers. Assessing and Managing Risks and Symptoms During initial meetings with patients, APRNs conduct comprehensive assessments of the unique symptoms experienced by each older adult e. Depending on patient medical history, other domains assessed also may include: fall risk Shumway-Cook et al. Collaborating Use of health information technology Promoting Continuity Between in-person visits, APRNs contact patients by phone and they are available by telephone seven days a week.