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Cited by 309Hospital Admissions and OutcomesAdolescent and Pediatric HealthcareGeriatric Care and Nursing Homes

Transitional care

Open access
Naylor, Mary, Keating, Stacen A.·2008·AJN, American Journal of Nursing
DOI 10.1097/01.naj.0000336420.34946.3aPMC PMC2768550
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Abstract

In Brief Moving patients from one care setting to another. Moving patients from one care setting to another.

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Crossref · 10.1097/01.naj.0000336420.34946.3a

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  • Fragmentation is particularly problematic for people with dementia who may have difficulty communicating their needs and medical history, increasing their risk of adverse outcomes during transitions.

    “This fragmentation was particularly problematic for people with dementia who may have difficulty communicating their needs and medical history, increasing their risk of adverse outcomes during transitions”

    From Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers. (2026) · cites this paper as Naylor & ­Keating, 2008

    The opening section links poor communication and incomplete information transfer during care transitions to gaps in care, and links poor handoffs for older adults to adverse events. It does not say that fragmentation is particularly problematic for people with dementia or that difficulty communicating their needs and medical history explains their risk. The copy provides no page number for these passages. (LLM, conf=0.87)

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Cites

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Research works printed but not linked: 35

  1. [1]Coleman EA Boult C Improving the quality of transitional care for persons with complex care needs J Am Geriatr Soc 2003 51 4 556 7 12657079
  2. [2]Naylor MD Nursing intervention research and quality of care: influencing the future of healthcare Nurs Res 2003 52 6 380 5 14639084
  3. [4]Burt CW McCaig LF Trends in hospital emergency department utilization: United States, 1992–99 Vital Health Stat 13 2001 150 1 34 11577602
  4. [5]Gabrel CS Jones A The National Nursing Home Survey: 1997 summary Vital Health Stat 13 2000 147 1 121 http://www.cdc.gov/nchs/data/series/sr_13/sr13_147.pdf 10957881
  5. [7]Coleman EA Posthospital care transitions: patterns, complications, and risk identification Health Serv Res 2004 39 5 1449 65 15333117 PMC1361078
  6. [8]Naylor MD Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial JAMA 1999 281 7 613 20 10029122
  7. [9]Naylor MD A decade of transitional care research with vulnerable elders J Cardiovasc Nurs 2000 14 3 1 14 10756470
  8. [11]Forster AJ The incidence and severity of adverse events affecting patients after discharge from the hospital Ann Intern Med 2003 138 3 161 7 12558354
  9. [12]Moore C Medical errors related to discontinuity of care from an inpatient to an outpatient setting J Gen Intern Med 2003 18 8 646 51 12911647 PMC1494907
  10. [13]Wenger NS Young RT Quality indicators for continuity and coordination of care in vulnerable elders J Am Geriatr Soc 2007 55 Suppl 2 S285 S292 17910549
  11. [14]Harrison MB Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition Med Care 2002 40 4 271 82 12021683
  12. [16]Weaver FM Patients’ and caregivers’ transition from hospital to home: needs and recommendations Home Health Care Serv Q 1998 17 3 27 48 10351068
  13. [18]Vinson JM Early readmission of elderly patients with congestive heart failure J Am Geriatr Soc 1990 38 12 1290 5 2254567
  14. [19]Levine C “This case is closed”: family caregivers and the termination of home health care services for stroke patients Milbank Q 2006 84 2 305 31 16771820 PMC2690166
  15. [20]Schumacher K Family caregivers: caring for older adults, working with their families Am J Nurs 2006 106 8 40 9 16905931
  16. [21]Kodner DL Kyriacou CK Bringing managed care home to people with chronic, disabling conditions: prospects and challenges for policy, practice, and research J Aging Health 2003 15 1 189 22 12613468
  17. [22]Kane RL Effect of an innovative Medicare managed care program on the quality of care for nursing home residents Gerontologist 2004 44 1 95 103 14978325
  18. [23]Abdallah LM EverCare nurse practitioner practice activities: similarities and differences across five sites J Am Acad Nurse Pract 2005 17 9 355 62 16115114
  19. [24]Leff B Hospital at Home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients Ann Intern Med 2005 143 11 798 808 16330791
  20. [25]Leff B Satisfaction with Hospital at Home care J Am Geriatr Soc 2006 54 9 1355 63 16970642
  21. [26]Neff DF APN-directed transitional home care model: achieving positive outcomes for patients with COPD Home Healthc Nurse 2003 21 8 543 50 12917525
  22. [27]Evans LK Yurkow J Balanced Budget Act of 1997 impact on a nurse-managed academic nursing practice for frail elders Nurs Econ 1999 17 5 280 2 10711179
  23. [28]Yu F Functional outcomes for older adults with cognitive impairment in a comprehensive outpatient rehabilitation facility J Am Geriatr Soc 2005 53 9 1599 606 16137294
  24. [29]Evans LK The CARE Program: a nurse-managed collaborative outpatient program to improve function of frail older people. Collaborative Assessment and Rehabilitation for Elders J Am Geriatr Soc 1995 43 10 1155 60 7560709
  25. [30]Foust JB Opportunities for improving post-hospital home medication management among older adults Home Health Care Serv Q 2005 24 1–2 101 22 16236662
  26. [31]Panno JM Acute Care for Elders (ACE): a holistic model for geriatric orthopaedic nursing care Orthop Nurs 2000 19 6 53 60 11899309
  27. [32]Bull MJ A professional-patient partnership model of discharge planning with elders hospitalized with heart failure Appl Nurs Res 2000 13 1 19 28 10701280
  28. [33]Rich MW A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure N Engl J Med 1995 333 18 1190 5 7565975
  29. [34]Coleman EA Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention J Am Geriatr Soc 2004 52 11 1817 25 15507057
  30. [35]Coleman EA The Care Transitions Intervention: results of a randomized controlled trial Arch Intern Med 2006 166 17 1822 8 17000937
  31. [36]Naylor M Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial Ann Intern Med 1994 120 12 999 1006 8185149
  32. [37]Zimmerman J Dabelko HI Collaborative models of patient care: new opportunities for hospital social workers Soc Work Health Care 2007 44 4 33 47 17804340
  33. [38]Nishita CM Transitioning residents from nursing facilities to community living: who wants to leave? J Am Geriatr Soc 2008 56 1 1 7 18184201
  34. [39]Silverstein B Usefulness of the nursing home quality measures and quality indicators for assessing skilled nursing facility rehabilitation outcomes Arch Phys Med Rehabil 2006 87 8 1021 5 16876545 PMC1861822
  35. [41]Kelley LS Access to health care resources for family caregivers of elderly persons with dementia Nurs Outlook 1999 47 1 8 14 10070648

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Authors
Naylor, M., & Keating, S. A.
Affiliations
University of Pennsylvania (US)
ORCID
Venue
AJN, American Journal of Nursing
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2008-09
Volume
108
Issue
9
Pages
58-63
ISSN
0002-936X (ISSN-L)
DOI
10.1097/01.naj.0000336420.34946.3a
PMC
PMC2768550
OpenAlex
W2327633171
Cited by
309
References
2
Citations by year
2026: 10 · 2025: 19 · 2024: 25 · 2023: 22 · 2022: 32 · 2021: 28 · 2020: 17 · 2019: 21 · 2018: 23 · 2017: 15 · 2016: 22 · 2015: 17 · 2014: 15 · 2013: 10 · 2012: 10
FWCI
1.57
Type
journal article
Language
en
Open access
Locations
  • AJN American Journal of Nursing (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (5p30nr005043-10)
  • National Institute on Aging (R01AG023116)
  • National Institute of Nursing Research (P30-NR-005043)
Topics
  • Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
  • Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
  • Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
Keywords
care transitions, patient transfer, continuity of care
MeSH terms
Aged, Chronic Disease, Communication, Community Health Nursing, Continuity of Patient Care, Day Care, Medical, Diffusion of Innovation, Family, Geriatric Nursing, Health Services for the Aged, Health Services Needs and Demand, Home Care Services, Humans, Patient Transfer, Reimbursement, Incentive, Social Support, Nursing Research, Models, Nursing, Caregivers, Total Quality Management, Evidence-Based Medicine, Quality Indicators, Health Care

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