Nursing Commons^™

Using A Dnp-Led Transitional Care Program To Prevent Rehospitalization In Elderly Patients With Heart Failure Or Chronic Obstructive Pulmonary Disease, Moira L. Long,

Doctor of Nursing Practice (DNP) Projects

ABSTRACT: TRANSITIONAL CARE FOR PATIENTS WITH CHRONIC DISEASE

BACKGROUND OF PROBLEM:

The Affordable Care Act of 2010 has put a spotlight on ensuring safe patient transfers between health care settings to prevent rehospitalization. Hospital readmissions are often influenced by a lack of outpatient transitional care programs to ensure the continuity of care during the transition from the inpatient setting to home. This gap in continuity further exacerbates the issues of patient management of medication regimens, adverse drug events, and follow-up with providers. These exacerbations combined with ineffective symptom management can all result in decompensation and rehospitalization. An extensive review of …