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Implementation Of A Nurse-Led Transitional Care Model For Older Adults With Copd Admitted To Home Health, Michelle Ryan Hunt

Doctor of Nursing Practice Projects

Problem Description: The importance of management of chronic disease and preventing rehospitalization has been identified at national and local levels. Chronic obstructive pulmonary disease (COPD) is one of the chronic diseases with notable rates of emergency department use and recurrence of hospitalizations.

Rationale: Implementation of transitional care models have been successful for health care organizations in chronic disease management.

Interventions: The health-social partnership transitional care management program (HSTCMP) was used to design a transitional care model process pilot for a home health agency (HHA) within a health system. This process used a multidisciplinary team led by a registered nurse for …