A qualitative analysis of an advanced practice nurse-directed transitional care model intervention
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PURPOSE: The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs). DESIGN AND METHODS: APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences. RESULTS: Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond. IMPLICATIONS: APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.
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Prior research suggests that people with dementia and caregivers may experience a period of adjustment that limits their ability to recognize new safety risks and make plans to address them.
“Prior research suggests that PWD and caregivers may experience a period of adjustment that limits their ability to recognize new safety risks and make plans to address them.14, 29, 30”
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Cites
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975) · Journal of Psychiatric Research · doi:10.1016/0022-3956(75)90026-6 · Cited by 88,282 · see citing works
Three Approaches to Qualitative Content Analysis
Hsieh, H.-F., & Shannon, S. E. (2005) · Qualitative Health Research · doi:10.1177/1049732305276687 · Cited by 44,601 · see citing works
Hirono, N., Mori, E., Ikejiri, Y., Imamura, T., Shimomura, T., Hashimoto, M., Yamashita, H., & Ikeda, M. (1997) · PubMed · Cited by 21,010 · see citing works
Graneheim, U. H., & Lundman, B. (2004) · Nurse Education Today · doi:10.1016/j.nedt.2003.10.001 · Cited by 20,772 · see citing works
Kok, J. S., Berg, I. J., & Scherder, E. J. A. (2013) · Dementia and Geriatric Cognitive Disorders Extra · doi:10.1159/000353441 · Cited by 20,589 · see citing works
Older Adults' Reasons for Using Technology while Aging in Place
Peek, S. T. M., Luijkx, K. G., Rijnaard, M. D., Nieboer, M. E., van der Voort, C. S., Aarts, S., van Hoof, J., Vrijhoef, H. J., & Wouters, E. (2015) · Gerontology · doi:10.1159/000430949 · Cited by 19,803 · see citing works
Sensitivity and False Alarm Rate of a Fall Sensor in Long-Term Fall Detection in the Elderly
Kangas, M., Korpelainen, R., Vikman, I., Nyberg, L., & Jämsä, T. J. (2014) · Gerontology · doi:10.1159/000362720 · Cited by 19,003 · see citing works
Criteria for assessing the trustworthiness of naturalistic inquiries
Guba, E. G. (1981) · ECTJ · doi:10.1007/bf02766777 · Cited by 5,527 · see citing works
The quality of health care delivered to adults in the United States
McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., & Kerr, E. A. (2003) · New England Journal of Medicine · doi:10.1056/nejmsa022615 · Cited by 5,079 · see citing works
Inouye, S. K. (2006) · New England Journal of Medicine · doi:10.1056/nejmra052321 · Cited by 2,091 · see citing works
The Care Transitions Intervention: Results of a Randomized Controlled Trial
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006) · Archives of Internal Medicine · doi:10.1001/archinte.166.17.1822 · Cited by 1,937 · see citing works
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999) · JAMA · doi:10.1001/jama.281.7.613 · Cited by 1,831 · see citing works
Methodological rigour within a qualitative framework
Tobin, G. A., & Begley, C. M. (2004) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2004.03207.x · Cited by 1,601 · see citing works
Six-item screener to identify cognitive impairment among potential subjects for clinical research
Callahan, C. M., Unverzagt, F. W., Hui, S. L., Perkins, A. J., & Hendrie, H. C. (2002) · Medical Care · doi:10.1097/00005650-200209000-00007 · Cited by 1,499 · see citing works
Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial
Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52202.x · Cited by 1,365 · cited 3× · see citing works
“…focused on interventions aimed at easing the transition for older adult patients as they move between hospital and home settings, using APNs as a “transitions coach” (Coleman, Parry, Chalmers, & Min, 2006) or testing an APN-directed TCM (M. Naylor et al., 1994; M. D. Naylor et al., 1999, 2004).”
MethodResultCauses and consequences of comorbidity
Gijsen, R., Hoeymans, N., Schellevis, F. G., Ruwaard, D., Satariano, W. A., & van den Bos, G. A. M. (2001) · Journal of Clinical Epidemiology · doi:10.1016/s0895-4356(00)00363-2 · Cited by 962 · see citing works
CLOX: an executive clock drawing task
Royall, D. R., Cordes, J. A., & Polk, M. J. (1998) · Journal of Neurology Neurosurgery & Psychiatry · doi:10.1136/jnnp.64.5.588 · Cited by 839 · see citing works
Comprehensive Discharge Planning for the Hospitalized Elderly
Naylor, M. D., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. V. (1994) · Annals of Internal Medicine · doi:10.7326/0003-4819-120-12-199406150-00005 · Cited by 730 · see citing works
(2014) · Fordham University Press eBooks · doi:10.2307/j.ctt9qdsck.5 · Cited by 679 · see citing works
(2013) · Routledge eBooks · doi:10.4324/9780203494035-16 · Cited by 663 · see citing works
Bracketing in Research: A Typology
Gearing, R. E. (2004) · Qualitative Health Research · doi:10.1177/1049732304270394 · Cited by 546 · see citing works
Appraising the quality of qualitative research
Walsh, D., & Downe, S. (2006) · Midwifery · doi:10.1016/j.midw.2005.05.004 · Cited by 523 · see citing works
Bynum, J. P. W., Rabins, P. V., Weller, W., Niefeld, M., Anderson, G. F., & Wu, A. W. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52054.x · Cited by 405 · see citing works
Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C. F., & Leff, B. A. (2009) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2009.02571.x · Cited by 342 · see citing works
The effects of cognitive impairment on mortality among hospitalized patients with heart failure
Zuccalà, G., Pedone, C., Cesari, M., Onder, G., Pahor, M., Marzetti, E., Monaco, M. R. L., Cocchi, A., Carbonin, P., & Bernabei, R. (2003) · The American Journal of Medicine · doi:10.1016/s0002-9343(03)00264-x · Cited by 318 · see citing works
Naylor, M., & Keating, S. A. (2008) · AJN, American Journal of Nursing · doi:10.1097/01.naj.0000336420.34946.3a · Cited by 309 · see citing works
Retooling for an Aging America
Institute of Medicine (2008) · National Academies Press eBooks · doi:10.17226/12089 · Cited by 202 · see citing works
Guided Care for Multimorbid Older Adults
Boyd, C. M., Boult, C., Shadmi, E., Leff, B. A., Brager, R., Dunbar, L., Wolff, J. L., & Wegener, S. T. (2007) · The Gerontologist · doi:10.1093/geront/47.5.697 · Cited by 198 · see citing works
[Qualitative research in nursing].
Mortensen, R. A. (1992) · PubMed · Cited by 183 · see citing works
Bell, C. M., Araki, S. S., & Neumann, P. J. (2001) · Alzheimer Disease & Associated Disorders · doi:10.1097/00002093-200107000-00004 · Cited by 156 · see citing works
Transitional Care of Older Adults
Naylor, M. D. (2002) · Annual Review of Nursing Research · doi:10.1891/0739-6686.20.1.127 · Cited by 154 · see citing works
Bauer, J. C. (2010) · Journal of the American Academy of Nurse Practitioners · doi:10.1111/j.1745-7599.2010.00498.x · Cited by 147 · see citing works
Barriers and Facilitators to Shared Decision-making Among African-Americans with Diabetes
Peek, M. E., Wilson, S. C., Gorawara‐Bhat, R., Odoms‐Young, A. M., Quinn, M. T., & Chin, M. H. (2009) · Journal of General Internal Medicine · doi:10.1007/s11606-009-1047-0 · Cited by 135 · see citing works
Translating research into practice: transitional care for older adults
Naylor, M. D., Feldman, P. H., Keating, S. A., Koren, M. J., Kurtzman, E. T., Maccoy, M. C., & Krakauer, R. S. (2009) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2009.01308.x · Cited by 133 · see citing works
Brooten, D. A., Naylor, M. D., York, R., Brown, L. P., Munro, B. H., Hollingsworth, A. O., Cohen, S. M., Finkler, S. A., Deatrick, J. A., & Youngblut, J. M. (2002) · Journal of Nursing Scholarship · doi:10.1111/j.1547-5069.2002.00369.x · Cited by 130 · see citing works
Effects of a geriatric nurse practitioner on process and outcome of nursing home care.
Kane, R. L., Garrard, J. M., Skay, C. L., Radosevich, D. M., Buchanan, J. L., McDermott, S., Arnold, S. B., & Kepferle, L. (1989) · American Journal of Public Health · doi:10.2105/ajph.79.9.1271 · Cited by 128 · see citing works
Cognitively Impaired Older Adults: From Hospital To Home
Naylor, M. D., Stephens, C. E., Bowles, K. H., & Bixby, M. B. (2005) · AJN American Journal of Nursing · doi:10.1097/00000446-200502000-00028 · Cited by 117 · see citing works
Care Transitions and Home Health Care
Boling, P. A. (2009) · Clinics in Geriatric Medicine · doi:10.1016/j.cger.2008.11.005 · Cited by 114 · see citing works
Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure
McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006) · Disease Management · doi:10.1089/dis.2006.9.302 · Cited by 114 · see citing works
Ryden, M. B., Snyder, M., Gross, C. R., Savik, K., Pearson, V., Krichbaum, K. E., & Mueller, C. (2000) · The Gerontologist · doi:10.1093/geront/40.6.654 · Cited by 101 · see citing works
Feasibility of Family Participation in a Delirium Prevention Program for Hospitalized Older Adults
Rosenbloom, D. A., Henneman, E. A., & Inouye, S. K. (2010) · Journal of Gerontological Nursing · doi:10.3928/00989134-20100330-02 · Cited by 98 · see citing works
From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors
Graham, C. L., Ivey, S. L., & Neuhauser, L. (2009) · The Gerontologist · doi:10.1093/geront/gnp005 · Cited by 90 · see citing works
Rethinking Intervention Strategies in Stroke Family Caregiving
Lutz, B. J., & Young, M. E. (2010) · Rehabilitation Nursing · doi:10.1002/j.2048-7940.2010.tb00041.x · Cited by 83 · see citing works
Golden, A. G., Tewary, S., Dang, S., & Roos, B. A. (2010) · The Gerontologist · doi:10.1093/geront/gnq015 · Cited by 83 · see citing works
Care Coordination for Cognitively Impaired Older Adults and Their Caregivers
Naylor, M. D., Hirschman, K. B., Bowles, K. H., Bixby, M. B., Konick-McMahan, J., & Stephens, C. E. (2007) · Home Health Care Services Quarterly · doi:10.1300/j027v26n04_05 · Cited by 79 · see citing works
The Six‐item Screener to Detect Cognitive Impairment in Older Emergency Department Patients
Wilber, S. T., Carpenter, C. R., & Hustey, F. M. (2008) · Academic Emergency Medicine · doi:10.1111/j.1553-2712.2008.00158.x · Cited by 70 · see citing works
Galik, E. M., Resnick, B. M., & Pretzer‐Aboff, I. (2009) · International Journal of Nursing Practice · doi:10.1111/j.1440-172x.2008.01721.x · Cited by 67 · see citing works
Sands, L. P., Yaffe, K. S., Lui, L., Stewart, A., Eng, C., & Covinsky, K. E. (2002) · The Journals of Gerontology Series A · doi:10.1093/gerona/57.7.m449 · Cited by 66 · see citing works
Cognitive Impairment, Chronic Medical Illness, and Risk of Mortality in an Elderly Cohort
Feil, D. G., Marmon, T., & Unützer, J. (2003) · American Journal of Geriatric Psychiatry · doi:10.1097/00019442-200309000-00010 · Cited by 55 · see citing works
White, C. L., Korner-Bitensky, N. A., Rodrigue, N., Rosmus, C., Sourial, R., Lambert, S., & Wood-Dauphinée, S. (2007) · PubMed · Cited by 54 · see citing works
Communication Difficulties in Hospitalized Older Adults with Dementia
Miller, C. A. (2008) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000311828.13935.1e · Cited by 52 · see citing works
Physician-Guided Treatment Compared With a Heparin Protocol for Deep Vein Thrombosis
Elliott, C. G. (1994) · Archives of Internal Medicine · doi:10.1001/archinte.154.9.999 · Cited by 45 · see citing works
Advanced Practice Nursing in the Care of Frail Older Adults
Bourbonniere, M., & Evans, L. K. (2002) · Journal of the American Geriatrics Society · doi:10.1046/j.1532-5415.2002.50621.x · Cited by 41 · see citing works
Brooten, D. A., Naylor, M., Campbell, R. L., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (2011) · Cited by 41 · see citing works
Lutz, B. J., Chumbler, N. R., & Roland, K. (2007) · Topics in Stroke Rehabilitation · doi:10.1310/tsr1402-32 · Cited by 37 · see citing works
Learning from Patients: A Discharge Planning Improvement Project
REILEY, P. J., Pike, A. W., Phipps, M. A., Weiner, M., Miller, N. A., Stengrevics, S. S., Clark, L., & Wandel, J. C. (1996) · The Joint Commission Journal on Quality Improvement · doi:10.1016/s1070-3241(16)30235-8 · Cited by 33 · see citing works
Applying the Transitional Care Model to Elderly Patients with Heart Failure
Bixby, M. B., Konick-McMahon, J., & McKenna, C. (2000) · The Journal of Cardiovascular Nursing · doi:10.1097/00005082-200004000-00008 · Cited by 22 · see citing works
Acute Care for Elders (ACE): A Holistic Model for Geriatric Orthopaedic Nursing Care
Panno, J. M., Kolcaba, K. Y., & Holder, C. M. (2000) · Orthopaedic Nursing · doi:10.1097/00006416-200019060-00010 · Cited by 20 · see citing works
A multimethod study of advanced practice nurse postdischarge care.
Dellasega, C. A., & Zerbe, T. M. (2000) · PubMed · Cited by 17 · see citing works
Heart Failure in Older Adults: Providing Nursing Care to Improve Outcomes
Konick-McMahan, J., Bixby, B., & McKenna, C. (2003) · Journal of Gerontological Nursing · doi:10.3928/0098-9134-20031201-08 · Cited by 16 · see citing works
Liggins, C., Pryor, L., & Bernard, M. (2010) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2010.03157.x · Cited by 13 · see citing works
Anton, E., & Marti, J. (2006) · New England Journal of Medicine · doi:10.1056/nejmc061003 · Cited by 12 · see citing works
Telephone Contacts in the Decision-Making Process
Sloane, P. D., Lekan-Rutledge, D. A., & Gilchrist, P. (1986) · Journal of Gerontological Nursing · doi:10.3928/0098-9134-19860801-09 · Cited by 11 · see citing works
Extreme regression models for characterizing high‐cost patients
Gregori, D., Petrinco, M., Barbati, G., Bo, S., Desideri, A., Zanetti, R., Merletti, F., & Pagano, E. (2009) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2008.00976.x · Cited by 10 · see citing works
A Model Preschool Vision and Hearing Screening Program
Crowley, A. A., Bains, R. M., & Pellico, L. H. (2005) · AJN American Journal of Nursing · doi:10.1097/00000446-200506000-00027 · Cited by 8 · see citing works
Cognitive Impairment, Chronic Medical Illness, and Risk of Mortality in an Elderly Cohort
Feil, D. (2003) · American Journal of Geriatric Psychiatry · doi:10.1176/appi.ajgp.11.5.551 · Cited by 7 · see citing works
Melton, L. P. (2005) · AJN American Journal of Nursing · doi:10.1097/00000446-200503000-00022 · Cited by 6 · see citing works
Community-Based Care Model for High-Risk Adults with Severe Disabilities
Naylor, M. D., Hill-Milbourne, V. R., Knoble, S. R., Robinson, K. M., Bowles, K. H., & Maislin, G. (2007) · Home Health Care Management & Practice · doi:10.1177/1084822306298784 · Cited by 3 · see citing works
Subjectively appreciated benefits from cognitive fitness interventions in older women
Klusmann, V., Evers, A. W. M., Schwarzer, R., et al. (2010) · Repository of Futwangen University of Applied Sciences (Furtwangen University) · doi:10.1093/geront/gnq115
Flagged first, then by citations
Research works printed but not linked: 1
- Anderson, K. (2010). Transitions of care: Assessing patient cognition and medication management skills. Annals of Long-Term Care, 18, 20-24.
Cited by
Sorted by citations
Best care at lower cost: the path to continuously learning health care in America
Smith, M. A., Saunders, R., Stuckhardt, L., & McGinnis, J. M. (2014) · Choice Reviews Online · doi:10.5860/choice.51-3277 · Cited by 1,356 · see citing works
Institute of Medicine (2013) · National Academies Press eBooks · doi:10.17226/13444 · Cited by 150 · see citing works
Altfeld, S. J., Shier, G. E., Rooney, M., Johnson, T. J., Golden, R., Karavolos, K., Avery, E., Nandi, V., & Perry, A. J. (2012) · The Gerontologist · doi:10.1093/geront/gns109 · Cited by 137 · see citing works
Naylor, M. D., Hirschman, K. B., Hanlon, A. L., Bowles, K. H., Bradway, C., McCauley, K. M., & Pauly, M. V. (2014) · Journal of Comparative Effectiveness Research · doi:10.2217/cer.14.14 · Cited by 91 · see citing works
Care of the Older Adult in the Emergency Department: Nurses Views of the Pressing Issues
Boltz, M. P., Parke, B., Shuluk, J., Capezuti, E., & Galvin, J. E. (2013) · The Gerontologist · doi:10.1093/geront/gnt004 · Cited by 90 · see citing works
Patient and family members’ perceptions of family participation in care on acute care wards
Mackie, B. R., Mitchell, M. L., & Marshall, A. P. (2018) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.12631 · Cited by 73 · see citing works
The Role of the Nurse and the Preoperative Assessment in Patient Transitions
Malley, A., Kenner, C. A., Kim, T., & Blakeney, B. (2015) · AORN Journal · doi:10.1016/j.aorn.2015.06.004 · Cited by 73 · see citing works
Fakha, A., Groenvynck, L., de Boer, B., van Achterberg, T., Hamers, J. P. H., & Verbeek, H. (2021) · Implementation Science · doi:10.1186/s13012-021-01087-2 · Cited by 70 · see citing works
Vetter, T. R., Ivankova, N. V., Goeddel, L. A., McGwin, G., & Pittet, J. (2013) · Anesthesiology · doi:10.1097/aln.0b013e3182a8e9e6 · Cited by 70 · see citing works
Exploring Care Transitions From Patient, Caregiver, and Health-Care Provider Perspectives
Fuji, K. T., Abbott, A. A., & Norris, J. F. (2012) · Clinical Nursing Research · doi:10.1177/1054773812465084 · Cited by 70 · see citing works
Transitional care: Concept analysis using Rodgers’ evolutionary approach
Shahsavari, H., Zarei, M., & Mamaghani, J. A. (2019) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2019.103387 · Cited by 62 · see citing works
Fealy, G., Casey, M., O’Leary, D., McNamara, M. S., O’Brien, D., O’Connor, L., Smith, R., & Stokes, D. (2018) · Journal of Clinical Nursing · doi:10.1111/jocn.14550 · Cited by 58 · see citing works
The role of the dementia specialist nurse in acute care: a scoping review
Griffiths, P., Bridges, J., Sheldon, H., & Thompson, R. (2014) · Journal of Clinical Nursing · doi:10.1111/jocn.12717 · Cited by 55 · see citing works
Bellon, J. E., Bilderback, A. L., Ahuja, N., Wilson, C., Dunn, S. C. A., Brodine, D., & Boninger, M. L. (2018) · Journal of the American Geriatrics Society · doi:10.1111/jgs.15643 · Cited by 52 · see citing works
Wang, Y., Yang, F., Shi, H., Yang, C., & Hu, H. (2017) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph14050510 · Cited by 51 · see citing works
Care transition interventions in mental health
Viggiano, T., Pincus, H. A., & Crystal, S. (2012) · Current Opinion in Psychiatry · doi:10.1097/yco.0b013e328358df75 · Cited by 48 · see citing works
Toward a process-level view of distributed healthcare tasks: Medication management as a case study
Werner, N. E., Malkana, S., Gürses, A. P., Leff, B. A., & Arbaje, A. I. (2017) · Applied Ergonomics · doi:10.1016/j.apergo.2017.06.020 · Cited by 47 · see citing works
Lim, S. Y., Järvenpää, S. L., & Lanham, H. J. (2015) · Journal of Management Information Systems · doi:10.1080/07421222.2015.1095013 · Cited by 42 · see citing works
Hovland, C. A., & Kramer, B. J. (2019) · Journal of Social Work in End-of-Life & Palliative Care · doi:10.1080/15524256.2019.1595811 · Cited by 30 · see citing works
Systematic review of planned care transitions for persons with dementia
Ray, C. A., Ingram, V., & Cohen-Mansfield, J. (2015) · Neurodegenerative Disease Management · doi:10.2217/nmt.15.23 · Cited by 29 · see citing works
Institutional Barriers Against Innovation Diffusion: From the Perspective of Digital Health Startups
Lim, S. Y., & Anderson, E. G. (2016) · Hawaii International Conference on System Sciences (HICSS) · doi:10.1109/hicss.2016.415 · Cited by 27 · see citing works
Transitional Care in the Patient-Centered Medical Home: Lessons in Adaptation
Hirschman, K. B., Shaid, E., Bixby, M. B., Badolato, D. J., Barg, R., Byrnes, M. B., Byrnes, R., Streletz, D., Stretton, J., & Naylor, M. D. (2016) · Journal for Healthcare Quality · doi:10.1097/01.jhq.0000462685.78253.e8 · Cited by 28 · see citing works
Mockford, C. (2015) · Journal of Healthcare Leadership · doi:10.2147/jhl.s70020 · Cited by 24 · see citing works
What is a nurse-led service? A discussion paper
Khair, K., & Chaplin, S. (2017) · The Journal of Haemophilia Practice · doi:10.17225/jhp00100 · Cited by 25 · see citing works
WALKER, R. B., Johns, J., & Halliday, D. (2014) · Health & Social Care in the Community · doi:10.1111/hsc.12142 · Cited by 24 · see citing works
Malley, A., Bourbonniere, M., & Naylor, M. D. (2018) · Journal of Clinical Nursing · doi:10.1111/jocn.14377 · Cited by 25 · see citing works
Welcoming Death: Exploring Pre-Death Grief Experiences of Caregivers of Older Adults with Dementia
Hovland, C. A. (2018) · Journal of Social Work in End-of-Life & Palliative Care · doi:10.1080/15524256.2018.1508538 · Cited by 16 · see citing works
Baldwin, K. M., Black, D. L., & Hammond, S. (2014) · Clinical Nurse Specialist · doi:10.1097/nur.0000000000000044 · Cited by 22 · see citing works
Prasad, S., Dunn, W., Hillier, L. M., McAiney, C. A., Warren, R., & Rutherford, P. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12982 · Cited by 22 · see citing works
Toles, M., Moriarty, H., Coburn, K., Marcantonio, S. A., Hanlon, A. L., Mauer, E. A., Fisher, P., O’Connor, M. L., Ulrich, C. M., & Naylor, M. D. (2015) · Journal of Applied Gerontology · doi:10.1177/0733464815602115 · Cited by 20 · see citing works
Positive Aspects of Family Caregiving for Older Adults at End-of-Life: A Qualitative Examination
Hovland, C. A., & Mallett, C. A. (2021) · Journal of Social Work in End-of-Life & Palliative Care · doi:10.1080/15524256.2021.1888845 · Cited by 18 · see citing works
Prática Avançada de Enfermagem: uma análise conceitual
Olímpio, J. D. A., Araújo, J. N. D. M., Pitombeira, D. O., Enders, B. C., Sonenberg, A., & Vítor, A. F. (2018) · Acta Paulista de Enfermagem · doi:10.1590/1982-0194201800092 · Cited by 17 · see citing works
Toles, M., Leeman, J., Gwyther, L., Vu, M., Vu, T., & Hanson, L. C. (2022) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2022.06.021 · Cited by 16 · see citing works
Examining nurse/patient relationships in care coordination: A qualitative metasynthesis
Luchsinger, J. S., Jones, J., McFarland, A. K., & Kissler, K. J. (2019) · Applied Nursing Research · doi:10.1016/j.apnr.2019.07.006 · Cited by 16 · see citing works
The Varying Roles of Nurses During Interfacility Care Transitions
Jeffs, L. P., Saragosa, M., Law, M. P., Kuluski, K., Espin, S., Parker, H., & Collins, K. (2017) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000248 · Cited by 14 · see citing works
Hospital-Community Partnerships to Aid Transitions for Older Adults
Hung, D. Y., Truong, Q. A., Yakir, M. J., & Nicosia, F. M. (2017) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000294 · Cited by 14 · see citing works
Studying Nursing Interventions in Acutely Ill, Cognitively Impaired Older Adults
McCauley, K. M., Bradway, C. K., Hirschman, K. B., & Naylor, M. D. (2014) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000454851.22018.5d · Cited by 13 · see citing works
Shannon, B., Shannon, H., Bowles, K., Williams, C., Andrew, N. E., & Morphet, J. (2022) · BMJ Open · doi:10.1136/bmjopen-2022-062437 · Cited by 12 · see citing works
Müller‐Staub, M., Zigan, N., Händler‐Schuster, D., Probst, S., Monego, R., & Imhof, L. (2015) · Pflege · doi:10.1024/1012-5302/a000410 · Cited by 12 · see citing works
Bartoli, D., Lombardi, E., Trotta, F., Macripo, S., Pucciarelli, G., & Petrosino, F. (2024) · Journal of Clinical Nursing · doi:10.1111/jocn.17591 · Cited by 10 · see citing works
Takahashi, P. Y., Finnie, D. M., Quigg, S. M., Borkenhagen, L. S., Kumbamu, A., Kimeu, A. K., & Griffin, J. M. (2018) · Clinical Interventions in Aging · doi:10.2147/cia.s183893 · Cited by 10 · see citing works
Meade, L. B., Hall, S. L., Kleppel, R., & Hinchey, K. T. (2015) · Journal of Community Hospital Internal Medicine Perspectives · doi:10.3402/jchimp.v5.26230 · Cited by 9 · see citing works
Høyem, A., Gammon, D., Berntsen, G., & Steinsbekk, A. (2018) · International Journal of Care Coordination · doi:10.1177/2053434518764643 · Cited by 9 · see citing works
A Concept Analysis of Individualized Aging
Cline, D. D. (2014) · Nursing Education Perspectives · doi:10.5480/12-1053.1 · Cited by 10 · see citing works
Hovland, C. A., & Mallett, C. A. (2021) · Journal of research in nursing · doi:10.1177/17449871211041682 · Cited by 8 · see citing works
Nguyen, T. (2022) · Dementia · doi:10.1177/14713012221101866 · Cited by 7 · see citing works
Rommerskirch‐Manietta, M., Manietta, C., Purwins, D., Braunwarth, J. I., Quasdorf, T., & Roes, M. (2023) · Implementation Science Communications · doi:10.1186/s43058-023-00486-4 · Cited by 8 · see citing works
Bradway, C. K., Bixby, M., Hirschman, K. B., McCauley, K. M., & Naylor, M. D. (2013) · Urologic Nursing · doi:10.7257/1053-816x.2013.33.4.177 · Cited by 7 · see citing works
Ruyobeza, B., Grobbelaar, S. S. S., & Botha, A. (2023) · Heliyon · doi:10.1016/j.heliyon.2023.e16885 · Cited by 5 · see citing works
Belowska, J., Pańczyk, M., & Gotlib, J. (2014) · Polish Journal of Public Health · doi:10.2478/pjph-2014-0031 · Cited by 5 · see citing works
The skill representation of a multimodal communication care method for people with dementia
Ishikawa, S., 伊東, 美., 本田, 美., & Takebayashi, Y. (2016) · International Conference on Global Research and Education (Inter-Academia) · doi:10.7567/jjapcp.4.011616 · Cited by 5 · see citing works
Sherlock, P. J. (2022) · Journal of the American Association of Nurse Practitioners · doi:10.1097/jxx.0000000000000690 · Cited by 5 · see citing works
Clarification de concept : la coordination appliquée au domaine des soins
Fishman, A. P., Leveau, E., Crelerot, S., Gentile, S., & Colson, S. (2016) · Revue Francophone Internationale de Recherche Infirmière · doi:10.1016/j.refiri.2016.02.001 · Cited by 5 · see citing works
Community Models of Care: A Scoping Review
Mullins, L. B., Skemp, L. E., & Maas, M. L. (2016) · Journal of Gerontological Nursing · doi:10.3928/00989134-20161110-05 · Cited by 4 · see citing works
Using a Scorecard to Demonstrate Clinical Nurse Specialistsʼ Contributions
Jepsen, S. L. (2015) · AACN Advanced Critical Care · doi:10.1097/nci.0000000000000066 · Cited by 4 · see citing works
Transition of patients from intensive care unit: A concept analysis
Ghorbanzadeh, K., Ebadi, A., Hosseini, M., Maddah, S. S. B., & Khankeh, H. R. (2022) · International Journal of Africa Nursing Sciences · doi:10.1016/j.ijans.2022.100498 · Cited by 5 · see citing works
Hovland, C. A. (2019) · Journal of Applied Gerontology · doi:10.1177/0733464819884267 · Cited by 4 · see citing works
Geriatric-Specific Standards for Information Transfer Between Nursing Homes and Acute Care Hospitals
Dale, M. C., Drickamer, M. A., & Sloane, P. D. (2020) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2020.02.015 · Cited by 4 · see citing works
Issues in access to end-of-life care in low-resource areas
Jain, Y. K., & Phutke, G. (2017) · Indian Journal of Medical Ethics · doi:10.20529/ijme.2017.091 · Cited by 3 · see citing works
The skill representation of a multimodal communication care method for people with dementia
Ishikawa, S., 伊東, 美., 本田, 美., & Takebayashi, Y. (2016) · JJAP Conference Proceedings · doi:10.56646/jjapcp.4.0_011616 · Cited by 3 · see citing works
Otis‐Green, S., Wakabayashi, M. T., Morgan, R. J., Hakim, A. A., FERRELL, B. R., Sun, V. C.-Y., Yang, E., & GRANT, M. M. (2012) · Journal of Palliative Medicine · doi:10.1089/jpm.2012.0174 · Cited by 3 · see citing works
Rouse, W. B., Naylor, M. D., Yu, Z., Pennock, M. J., Hirschman, K. B., Pauly, M. V., & Pepe, K. M. (2019) · Journal of Healthcare Management · doi:10.1097/jhm-d-18-00114 · Cited by 3 · see citing works
Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial
Sauers‐Ford, H. S., Tubbs‐Cooley, H. L., Statile, A. M., Pickler, R. H., White, C. M., Wade‐Murphy, S., Gold, J. M., Shah, S. S., Simmons, J. M., & On behalf of the H2O Study Group (2017) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000012 · Cited by 3 · see citing works
Bowles, K. H., Stawnychy, M. A., O’Connor, M. L., Mikkelsen, M. E., Hodgson, N. A., Sang, E., You, S. B., Pitcher, K. S., Song, J., Oh, S., et al. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1632083 · Cited by 3 · see citing works
Predischarge Provider Visits as a Method of Improving Transitional Care Clinic Visit Rates
James, T. C., Corbett, C. F., Jones, K. J., & Moore-Gibbs, A. (2020) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000467 · Cited by 2 · see citing works
Lim, S. Y., Järvenpää, S. L., & Lanham, H. J. (2015) · Hawaii International Conference on System Sciences (HICSS) · doi:10.1109/hicss.2015.380 · Cited by 2 · see citing works
Khemai, C., Meijers, J. M. M., Bolt, S., Pieters, S., Janssen, D. J. A., & Schols, J. M. G. A. (2023) · Aging & Mental Health · doi:10.1080/13607863.2023.2226079 · Cited by 2 · see citing works
Improving the implementation of transitional care innovations
Fakha, A. (2023) · doi:10.26481/dis.20230710af · Cited by 2 · see citing works
von der Lühe, V., Roos, M., Löbberding, M., Peter, S., Scholten, N., Köpke, S., & Dichter, M. (2025) · Journal of Advanced Nursing · doi:10.1111/jan.17053 · Cited by 1 · see citing works
Specialty Payment Model Opportunities and Design
McClellan, M., Patel, K., Botts, C., Presser, E., Grimes, C., Crim, C., & Tobin, J. (2014) · Cited by 1 · see citing works
New Models of Healthcare Delivery
Powers, J. S. (2018) · Springer eBooks · doi:10.1007/978-3-319-77057-4_5 · Cited by 1 · see citing works
Advanced Practice Nurses in Transitional Care: A Source to the Solution
Bottoms, H. (2014) · Cited by 1 · see citing works
Transition of Care for Older Adults Undergoing General Surgery
Persaud, E., Nissley, C., Piasecki, E., & Quinn, C. (2023) · Critical Care Nursing Clinics of North America · doi:10.1016/j.cnc.2023.05.009 · Cited by 1 · see citing works
Qiao, L., Li, S. G., Ma, H., Zhou, W., Zhang, J., Tang, X., Huang, R.-R., Wang, A., & Piao, M. (2025) · European Journal of Cardiovascular Nursing · doi:10.1093/eurjcn/zvaf192 · Cited by 1 · see citing works
Hovland, C. A., & Mallett, C. A. (2020) · OMEGA - Journal of Death and Dying · doi:10.1177/0030222820906684 · Cited by 1 · see citing works
Using big data methods to understand Alzheimer’s disease
Warren, S. L., Moustafa, A. A., & Alashwal, H. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-821334-6.00004-1 · Cited by 1 · see citing works
SPESIALISASI DALAM PRAKTIK KEBIDANAN: SCOPING REVIEW
Wulandari, D. I., Hidayah, N., Fatimah, S., Machfudloh, M., & Astuti, A. W. (2022) · Jurnal Kebidanan Indonesia · doi:10.36419/jki.v14i1.765 · Cited by 1 · see citing works
Rydeman, I. (2012) · Figshare · Cited by 1 · see citing works
A Doctor of Nursing Practice-Led Transitions of Care Model for Stroke and Transient Ischemic Attack
Haynes, H. N. (2013) · UA Campus Repository (The University of Arizona) · Cited by 1 · see citing works
Post-laminectomy Back Pain: Understanding the Progress from Acute to Chronic Pain State
Calhoun, J. D. (2014) · UKnowledge (University of Kentucky)
Dementia informal caregivers’ experience with hospital discharge planning post-discharge
Owusua, A. (2018) · Lu Zone Ul (Laurentian University)
McClellan, M., Patel, K., O'Shea, J. S., Botts, C., Presser, E., Grimes, C., Crim, C., & Tobin, J. (2014)
Rovito, C., & Fagan, K. (2022) · Journal of Doctoral Nursing Practice · doi:10.1891/jdnp-d-20-00072
Medication communication with older adults experiencing chronic illness and polypharmacy
Adelsjö, I. (2023) · doi:10.15626/lnulic.41.2023 · Cited by 1 · see citing works
Khemai, C. (2023) · doi:10.26481/dis.20231115ck
Advanced Practice Nurses in der Alterstraumatologie
Neumann, N., Peter, F., Lenz, R., Höhmann, U., Knecht, C., & Heitmann, D. (2023) · Zeitschrift für Gerontologie und Geriatrie · doi:10.1007/s00391-023-02243-7
Fakha, A., Groenvynck, L., de Boer, B., van Achterberg, T., Hamers, J. P. H., & Verbeek, H. (2021) · Figshare · doi:10.6084/m9.figshare.14129349
Fakha, A., Groenvynck, L., de Boer, B., van Achterberg, T., Hamers, J. P. H., & Verbeek, H. (2021) · Figshare · doi:10.6084/m9.figshare.14129343
Rommerskirch‐Manietta, M., Manietta, C., Purwins, D., Braunwarth, J. I., Quasdorf, T., & Roes, M. (2024) · Figshare · doi:10.6084/m9.figshare.26613335
Fakha, A., Groenvynck, L., de Boer, B., van Achterberg, T., Hamers, J. P. H., & Verbeek, H. (2021) · Figshare · doi:10.6084/m9.figshare.14129346
Ratsamesuviwat, J., Pusopa, C., & Settheekul, S. (2026) · Pacific Rim International Journal of Nursing Research · doi:10.60099/prijnr.2026.280446
The influence of doctor of nursing practice education on nurse practitioner practice
Christianson-Silva, P. (2015) · UA Campus Repository (The University of Arizona)
- Authors
- Bradway, C., Trotta, R., Bixby, M. B., McPartland, E., Wollman, M. C., Kapustka, H., McCauley, K., & Naylor, M. D.
- Affiliations
- University of Pennsylvania (US)
- Pennsylvania Hospital (US)
- Neumann University (US)
- Philadelphia VA Medical Center (US)
- Corresponding author
- Bradway, C.
- Venue
- The Gerontologist
- Publisher
- Oxford University Press (OUP)
- Published
- 2011-09-09
- Volume
- 52
- Issue
- 3
- Pages
- 394-407
- ISSN
- 0016-9013 (ISSN-L)
- 1758-5341
- PMC
- PMC3342512
- OpenAlex
- W2150824618
- Cited by
- 96
- References
- 68
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 2 · 2023: 8 · 2022: 7 · 2021: 7 · 2020: 3 · 2019: 5 · 2018: 10 · 2017: 7 · 2016: 7 · 2015: 13 · 2014: 13 · 2013: 5 · 2012: 5
- FWCI
- 13.65
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Gerontologist (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- University of Pennsylvania
- National Institute on Aging (R01AG023116)
- Topics
- Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Keywords
- Transitional Care Model, advanced practice nurses, cognitive impairment, older adults, caregivers, hospital-to-home transition, care coordination, implementation barriers and facilitators, caregiver experiences, reimbursement reform, individualized care
- MeSH terms
- Aged, Aged, 80 and over, Cognition Disorders, Continuity of Patient Care, Female, Home Care Services, Humans, Health Knowledge, Attitudes, Practice, Male, Middle Aged, Nurse Practitioners, Patient Transfer, Models, Nursing, Caregivers, Patient-Centered Care, Qualitative Research, Evidence-Based Nursing, Advanced Practice Nursing
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